Substance Abuse Treatment:
 

Addressing the Specifi c 


Needs of Women
 

A Treatment
 

Improvement
 

Protocol
 

TIP
 

51
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

www.samhsa.gov 

WMo
 
 SPECIFIC NEEDS
 

OF WOMEN
 
Substance Abuse Treatment: 


Addressing the 


Specific Needs of Women
 

A Treatment 


Improvement 


Protocol
 

TIP
 

51
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments 

This publication was produced by The CDM 

Group, Inc. (CDM) under the Knowledge Application Program (KAP) contract numbers 270­

99-7072 and 270-04-7049 with the Substance 

Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health 

and Human Services (HHS). Andrea Kopstein, 

Ph.D., M.P.H., Karl D. White, Ed.D., and 

Christina Currier served as the Center for Substance Abuse Treatment (CSAT) Government 

Project Offi cers. 

Disclaimer 

The views, opinions, and content expressed 

herein are those of the expert panel and do not 

necessarily reflect the views, opinions, or policies of CSAT, SAMHSA, or HHS. No offi cial 

support of or endorsement by CSAT, SAMHSA, 

or HHS for these opinions or for particular 

instruments, software, or resources is intended 

or should be inferred. 

Public Domain Notice 

All materials appearing in this volume except 

those taken directly from copyrighted sources 

are in the public domain and may be reproduced or copied without permission from 

SAMHSA/CSAT or the authors. Citation of the 

source is appreciated. However, this publication 

may not be reproduced or distributed for a fee 

without the specific, written authorization of 

the Office of Communications, SAMHSA, HHS. 

Electronic Access and Copies of 

Publication 

This publication may be downloaded or ordered 

at http://www.samhsa.gov/shin. Or, please call 

SAMHSA’s Health Information Network at 

1-877-SAMHSA-7 (1-877-726-4727) (English and 

Español). 

Recommended Citation 

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement 

Protocol (TIP) Series 51. HHS Publication 

No. (SMA) 09-4426. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 2009. 

Originating Offi ce 

Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 09-4426 

Printed 2009 

ii 
Contents 

Contents
 

What Is a TIP? ....................................................................................................... vii
 

Consensus Panel ......................................................................................................ix
 

Editorial Board........................................................................................................xi
 

KAP Expert Panel and Federal Government Participants .............................................. xiii
 

Foreword............................................................................................................... xv
 

Executive Summary............................................................................................... xvii
 

Chapter 1—Creating the Context ................................................................................ 1
 

Overview..................................................................................................................1
 

Creating the Context ...................................................................................................1
 

Gender Responsive Treatment Principles .........................................................................4
 

Women’s Biopsychosocial Uniqueness..............................................................................6
 

Organization of This TIP ........................................................................................... 15
 

Chapter 2—Patterns of Use: From Initiation to Treatment ..............................................17
 

Overview................................................................................................................ 17
 

Initiation of Use Among Women ................................................................................... 18
 

Risk Factors Associated with Initiation of Substance Use and the Development of Substance 


Use Disorders Among Women ................................................................................... 18
 

Patterns and Prevalence of Substance Use Among Women .................................................. 26
 

Prevalence of Substance Abuse and Dependence Among Women .......................................... 30
 

Chapter 3—Physiological Effects of Alcohol, Drugs, and Tobacco on Women .....................37
 

Overview................................................................................................................ 37
 

Physiological Effects and Consequences of Substance Abuse In Women ................................. 38
 

Physiological Effects: Factors of Infl uence ...................................................................... 38
 

Physiological Effects of Alcohol ................................................................................... 40
 

Physiological Effects of Licit and Illicit Drugs.................................................................. 46
 

Physiological Effects of Tobacco Use ............................................................................. 48
 

Effects of Alcohol, Drugs, and Tobacco Use on Pregnancy and Birth Outcomes ....................... 48
 

Effects of Alcohol and Illicit Drugs on HIV/AIDS Status..................................................... 52
 

Chapter 4—Screening and Assessment ........................................................................57
 

Overview................................................................................................................ 57
 

The Difference Between Screening and Assessment ........................................................... 58
 

Screening and Assessment: Factors of Infl uence ............................................................... 58
 

iii 
Screening ............................................................................................................... 60
 

Assessment ............................................................................................................. 74
 

Chapter 5—Treatment Engagement, Placement, and Planning .........................................83
 

Overview................................................................................................................ 83
 

Barriers to Treatment Engagement ............................................................................... 83
 

Treatment Engagement Strategies ................................................................................. 87
 

Considerations in Treatment Placement and Planning ....................................................... 92
 

Levels of Care ......................................................................................................... 92
 

Chapter 6—Substance Abuse Among Specific Population Groups and Settings ..................103
 

Overview...............................................................................................................103
 

Racially and Ethnically Diverse Women ........................................................................104
 

Sexual Orientation and Women ...................................................................................123
 

Women Later in Life ................................................................................................127
 

Women in Rural America ..........................................................................................130
 

Resources for Other Special Populations and Settings ......................................................133
 

Women in the Criminal Justice System ..........................................................................134
 

Women Who Are Homeless ........................................................................................135
 

Chapter 7—Substance Abuse Treatment for Women ....................................................137
 

Overview...............................................................................................................137
 

Treatment Retention ................................................................................................137
 

Women’s Treatment Issues and Needs ...........................................................................143
 

Addressing Tobacco Use with Women in Treatment ..........................................................177
 

Chapter 8—Recovery Management and Administrative Considerations ............................181
 

Overview...............................................................................................................181
 

Continuing Care .....................................................................................................181
 

Treatment Outcome .................................................................................................182
 

Support Systems for Women ......................................................................................186
 

Administrative Considerations....................................................................................187
 

Appendix A: Bibliography.......................................................................................197
 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model for 


Women and Their Children .................................................................................273
 

Appendix C: Screening and Assessment Instruments.....................................................297
 

Appendix D: Allen Barriers to Treatment Instrument ...................................................307
 

Appendix E: DSM-IV-TR Criteria for Posttraumatic Stress Disorder ...............................311
 

Appendix F: Integration Self-Assessment for Providers.................................................313
 

Appendix G: Resource Panel Members......................................................................319
 

Appendix H: Cultural Competency and Diversity Network Participants............................323
 

Appendix I: Field Reviewers....................................................................................325
 

Appendix J: Acknowledgments.................................................................................333
 

Index..................................................................................................................335
 

iv Contents 
 

Figures
 

1-1 A Woman’s Life in Context ....................................................................................3
 

2-1 Use of Illicit Drugs, Alcohol, or Tobacco by Females Aged 12 or Older, Past Year
 

2-2 Past Month Substance Use, Based on Combined 2006 and 2007 Data: 


2-3 Percentages of Past-Year Abuse of or Dependence on Alcohol or Any Illicit 


2-4 Percentages of Past-Year Abuse of or Dependence on Alcohol or 


2-5 Percentage of Admissions to Substance Abuse Treatment Programs by 


2-6 Primary Substance of Abuse Among Women Admitted for Substance 


5-1 Percentages of Reasons for Not Receiving Substance Use Treatment in the 


Past Year Among Women Aged 18–49 Who Needed Treatment and Who 


8-3 Goals and Training Guidelines for Point-of-Entry Staff (Non–Substance-Abuse 


1-2 Interrelated Elements in the Comprehensive Treatment Model .......................................4
 

and Past Month, Numbers in Thousands and Percentages, 2006 ................................... 29
 

National Survey on Drug Use and Health (NSDUH)................................................... 30
 

Drug by Gender and Age, 2006 ............................................................................. 31
 

Any Illicit Drug Among Women Aged 18 or Older by Age Group: 2003 ............................ 32
 

Racial/Ethnic Group in 2006................................................................................ 33
 

Abuse Treatment by Racial/Ethnic Group by Percentage. ........................................... 34
 

4-1 The CAGE Questionnaire.................................................................................... 62
 

4-2 The TWEAK Questionnaire: Women ...................................................................... 64
 

4-3 The T-ACE Questionnaire ................................................................................... 64
 

4-4 5Ps Screening .................................................................................................. 65
 

4-5 Questions to Screen for Trauma History ................................................................. 69
 

4-6 Questions Regarding Sexual Abuse. ....................................................................... 71
 

4-7 STaT: Intimate Partner Violence Screening Tool ....................................................... 72
 

4-8 General and Specific Screening Questions for Persons with Possible Eating Disorders ........ 73
 

4-9 Available Screening and Assessment Tools in Multiple Languages .................................. 80
 

Perceived a Need for It: 2004–2006 ....................................................................... 85
 

5-2 PROTOTYPES ................................................................................................ 91
 

5-3 Services Needed in Women’s Substance Abuse Treatment ............................................ 93
 

6-1 Group Therapy: Promising Practices and Strategies for African-American Women ...........113
 

7-1 Violence and Women .........................................................................................156
 

7-2 PTSD Symptoms ..............................................................................................162
 

7-3 Helpful Skills for Trauma Victims ........................................................................163
 

7-4 Common Definitions of Eating Disorders and Behaviors .............................................175
 

8-1 Women-Specific Predictors of Relapse and Reactions to Relapse ..................................184
 

8-2 Women’s Recovery Group: Manual-Based Relapse Prevention ....................................185
 

Treatment Providers) .....................................................................................190
 

8-4 Goals and Training Guidelines for Substance Abuse Treatment Counselors .....................191
 

8-5 State Standard Examples of Gender-Specifi c Treatment .............................................195
 

B-1 Interrelated Elements in the Comprehensive Treatment Model ....................................276
 

B-2 Elements of Clinical Treatment Services .................................................................277
 

B-3 Elements of Clinical Support Services ...................................................................279
 

Contents v 
B-4 Elements of Community Support Services ..............................................................280
 

B-5 Clinical Treatment Services for Children ................................................................281
 

B-6 Clinical Support Services for Children ..................................................................282
 

B-7 Interrelated Elements of Clinical Treatment and Support Services for 


Women and Their Children ................................................................................284
 

Advice to the Clinician and Administrator Boxes 

Chapter 2
 

Using Patterns of Use as a Clinical Guide ....................................................................... 35
 

Chapter 3
 

Substance Use and Birth Outcomes............................................................................... 50
 

Chapter 4
 

Culturally Responsive Screening and Assessment ............................................................. 59
 

Substance Abuse Screening and Assessment Among Women ................................................ 61
 

At-Risk Screening for Drug and Alcohol Use During Pregnancy ........................................... 66
 

Mental Health Screening and Women ............................................................................ 75
 

General Guidelines for Selecting and Using Screening and Assessment Tools ........................... 76
 

General Guidelines of Assessment for Women .................................................................. 81
 

Chapter 5
 

The Impact of Trauma and Prenatal Care .....................................................................102
 

Chapter 6
 

Substance Abuse Treatment and Hispanic/Latina Women ..................................................106
 

Substance Abuse Treatment and African-American Women ...............................................114
 

Substance Abuse Treatment and Asian- and Pacifi c-American Women ..................................116
 

Substance Abuse Treatment and Native-American Women .................................................121
 

Substance Abuse Treatment and Lesbian and Bisexual Women ...........................................125
 

Substance Abuse Treatment and Older Women ...............................................................129
 

Substance Abuse Treatment and Women in Rural Areas ...................................................132
 

Chapter 7
 

Relational Model Approach .......................................................................................144
 

Considerations in Involving the Partner in Treatment ......................................................146
 

Women with Co-Occurring Disorders ...........................................................................158
 

When is a Woman Ready for Trauma Processing? ...........................................................167
 

Retraumatization ....................................................................................................169
 

Women With Eating Disorders ....................................................................................177
 

Chapter 8
 

Postpartum Relapse Prevention..................................................................................186
 

vi Contents 
What is a TIP? 

What Is a TIP?
 

Treatment Improvement Protocols (TIPs) are developed by the Center 

for Substance Abuse Treatment (CSAT), part of the Substance Abuse 

and Mental Health Services Administration (SAMHSA) within the U.S. 

Department of Health and Human Services (HHS). TIPs are best-practice 

guidelines for the treatment of substance use disorders. TIPs draw on 

the experience and knowledge of clinical, research, and administrative 

experts to evaluate the quality and appropriateness of various forms 

of treatment. TIPs are distributed to facilities and individuals across 

the country. Published TIPs can be accessed via the Internet at 

http://www.kap.samhsa.gov. 

While each TIP strives to include an evidence base for the practices it 

recommends, SAMHSA/CSAT recognizes that the field of substance abuse 

treatment is continually evolving, and research frequently lags behind the 

innovations pioneered in the field. A major goal of each TIP is to convey 

“front-line” information quickly but responsibly. If research supports a 

particular approach, citations are provided. 

vii 
Consensus Panel 

Consensus Panel 


Chair 

Norma B. Finkelstein, Ph.D., M.S.W. 

Executive Director 

Institute for Health & Recovery 

Cambridge, Massachusetts 

Co-Chair 

Juana Mora, Ph.D. 

Professor 

Northridge Chicano/a Studies Department 

California State University, Northridge 

Northridge, California 

Workgroup Leaders 

Karen Allen, Ph.D., R.N., FAAN 

Professor/Chair 

Department of Nursing 

Andrews University 

Berrien Springs, Michigan 

Hortensia Amaro, Ph.D. 

Distinguished Professor 

Center on Health and Social Science Research 

Director 

Institute on Urban Health Research 

Northeastern University 

Boston, Massachusetts 

Stephanie S. Covington, Ph.D., LCSW 

Co-Director 

Center for Gender and Justice 

Institute for Relational Development 

La Jolla, California 

Francine Feinberg, Psy.D., CISCW 

Executive Director 

Meta House 

Whitefish Bay, Wisconsin 

Beth Glover Reed, Ph.D. 

Associate Professor 

Social Work and Women’s Studies 

School of Social Work 

University of Michigan 

Ann Arbor, Michigan 

Brenda L. Underhill, M.S., CAC 

President 

Underhill and Associates 

El Cerrito, California 

Panelists 

Belinda Biscoe, Ph.D. 

Assistant Vice President for Public and 

Community Services 

Director, Region VII Comprehensive Assistance 

Center 

Director, Education, Training, Evaluation, 

Assessment and Measurement Department 

(E-TEAM) 

University of Oklahoma 

Norman, Oklahoma 

Vivian B. Brown, Ph.D. 

Founder, Board Member Emeritus 

PROTOTYPES 

Culver City, California 

Margaret A. Cramer, Ph.D. 

Clinical Psychologist/Instructor 

Massachusetts General Hospital 

Boston, Massachusetts 

ix 
Gloria Grijalva-Gonzales 

Certified Sr. Substance Abuse Case Manager/ 

Counselor 

Allies Project 

San Joaquin County 

Stockton, California 

Tonda L. Hughes, Ph.D., R.N. 

Professor 

Department of Health Systems Science 

University of Illinois at Chicago 

Chicago, Illinois 

Marty A. Jessup, Ph.D., R.N., M.S. 

Associate Adjunct Professor 

Department of Family Health Care Nursing 

Institute for Health and Aging 

University of California, San Francisco 

San Francisco, California 

Karol A. Kaltenbach, Ph.D. 

Professor of Pediatrics–Psychiatry and 

Human Behavior 

Thomas Jefferson University 

Jefferson Medical College 

Philadelphia, Pennsylvania 

Robin A. LaDue, Ph.D. 

Clinical Psychologist 

Department of Psychiatry and 

Behavioral Sciences 

University of Washington 

Renton, Washington 

LaVerne R. Saunders, B.S.N., R.N., M.S. 

Founder/Partner 

Dorrington & Saunders and Associates 

Framingham, Massachusetts 

Starleen Scott-Robbins, M.S.W., LCSW 

Women’s Treatment Coordinator 

Best Practice Consultant 

Developmental Disabilities and Substance Abuse 

Services 

Division of Mental Health 

North Carolina Department of Health and 

Human Services 

Raleigh, North Carolina 

Sally J. Stevens, Ph.D. 

Executive Director 

Southwest Institute for Research on Women 

University of Arizona 

Tucson, Arizona 

Sharon Wilsnack, Ph.D. 

Professor 

Department of Clinical Neuroscience 

Medical School for the Public 

School of Medicine & Health Sciences 

University of North Dakota 

Grand Forks, North Dakota 

Rita Zimmer, M.P.H. 

Founder 

Women in Need, Inc. 

New York, New York 

x Consensus Panel 
Editorial Board 


Gene Burkett, M.D., B.S., FRCOG, FACOG, Diplomate American 

Board, OB/GYN 

Professor 

Obstetrics and Gynecology 

University of Miami School of Medicine 

Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS 

Professor of Clinical Psychiatry (Social Work) 

University of Cincinnati, College of Medicine 

Executive Director 

The Crossroads Center 

Grace Chang, M.D., M.P.H. 

Associate Professor of Psychiatry, 

Harvard Medical School 

Brigham and Women’s Hospital 

Elena Flores, Ph.D. 

Associate Professor 

Counseling Psychology Department 

School of Education 

University of San Francisco 

Jacki McKinney 

Executive Director 

National People of Color Consumer Survivor Network 

Lisa Najavits, Ph.D. 

Associate Professor of Psychology 

Harvard Medical School 

Dace Svikis, Ph.D. 

Associate Professor 

Virginia Commonwealth University 

William White, M.A. 

Senior Research Consultant 

Chestnut Health Systems/Lighthouse Institute 

Editorial Board xi 
KAP Expert Panel and Federal 

Government Participants 

Barry S. Brown, Ph.D. 

Adjunct Professor 

University of North Carolina at Wilmington 

Carolina Beach, North Carolina 

Jacqueline Butler, M.S.W., LISW, LPCC, 

CCDC III, CJS 

Professor of Clinical Psychiatry 

College of Medicine 

University of Cincinnati 

Cincinnati, Ohio 

Deion Cash 

Executive Director 

Community Treatment and Correction

 Center, Inc. 

Canton, Ohio 

Debra A. Claymore, M.Ed.Adm. 

Owner/Chief Executive Offi cer 

WC Consulting, LLC 

Loveland, Colorado 

Carlo C. DiClemente, Ph.D. 

Chair 

Department of Psychology 

University of Maryland Baltimore County 

Baltimore, Maryland 

Catherine E. Dube, Ed.D. 

Independent Consultant 

Brown University 

Providence, Rhode Island 

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief, Services 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Bethesda, Maryland 

Michael Galer, D.B.A. 

Chairman of the Graduate School of Business 

University of Phoenix - Greater Boston Campus 

Braintree, Massachusetts 

Renata J. Henry, M.Ed. 

Director 

Division of Alcoholism, Drug Abuse, 

and Mental Health 

Delaware Department of Health and Social 

Services 

New Castle, Delaware 

Joel Hochberg, M.A. 

President 

Asher & Partners 

Los Angeles, California 

Jack Hollis, Ph.D. 

Associate Director 

Center for Health Research 

Kaiser Permanente 

Portland, Oregon 

Mary Beth Johnson, M.S.W. 

Director 

Addiction Technology Transfer Center 

University of Missouri—Kansas City 

Kansas City, Missouri 

KAP Expert Panel and Federal Government Participants xiii 
Eduardo Lopez, B.S. 

Executive Producer 

EVS Communications 

Washington, DC 

Holly A. Massett, Ph.D. 

Academy for Educational Development 

Washington, DC 

Diane Miller 

Chief 

Scientific Communications Branch 

National Institute on Alcohol Abuse 

and Alcoholism 

Bethesda, Maryland 

Harry B. Montoya, M.A. 

President/Chief Executive Offi cer 

Hands Across Cultures 

Espanola, New Mexico 

Richard K. Ries, M.D. 

Director/Professor 

Outpatient Mental Health Services 

Dual Disorder Programs 

Seattle, Washington 

Gloria M. Rodriguez, D.S.W. 

Research Scientist 

Division of Addiction Services 

NJ Department of Health and Senior Services 

Trenton, New Jersey 

Everett Rogers, Ph.D. 

Center for Communications Programs 

Johns Hopkins University 

Baltimore, Maryland 

Jean R. Slutsky, P.A., M.S.P.H. 

Senior Health Policy Analyst 

Agency for Healthcare Research & Quality 

Rockville, Maryland 

Nedra Klein Weinreich, M.S. 

President 

Weinreich Communications 

Canoga Park, California 

Clarissa Wittenberg 

Director 

Office of Communications and Public Liaison 

National Institute of Mental Health 

Kensington, Maryland 

Consulting Members: 

Paul Purnell, M.A. 

Social Solutions, L.L.C. 

Potomac, Maryland 

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development 

Washington, DC 

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program 

Department of Preventive Medicine 

School of Medicine 

University of Southern California 

Alhambra, California 

Patricia A. Wright, Ed.D. 

Independent Consultant 

Baltimore, Maryland 

xiv KAP Expert Panel and Federal Government Participants 
Foreword


 The Treatment Improvement Protocol (TIP) 

series supports SAMHSA’s mission of building 

resilience and facilitating recovery for people 

with or at risk for mental or substance use 

disorders by providing best practices guidance 

to clinicians, program administrators, and payers to improve the quality and effectiveness of 

service delivery, and, thereby promote recovery. 

TIPs are the result of careful consideration of 

all relevant clinical and health services research 

findings, demonstration experience, and implementation requirements. A panel of clinical 

researchers, clinicians, program administrators, 

and client advocates debates and discusses its 

particular areas of expertise until it reaches a 

consensus on best practices. This panel’s work is 

then reviewed and critiqued by fi eld reviewers. 

The talent, dedication, and hard work that 

TIPs Panelists and reviewers bring to this highly 

participatory process have helped to bridge the 

gap between the promise of research and the 

needs of practicing clinicians and administrators 

to serve people who abuse substances in the 

most scientifically sound and effective ways. We 

are grateful to all who have joined with us to 

contribute to advances in the substance abuse 

treatment fi eld. 

Eric Broderick, D.D.S., M.P.H. 

Acting Administrator 

Substance Abuse and Mental Health Services 

Administration 

H. Westley Clark, M.D., J.D., M.P.H., CAS, 

FASAM 

Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Foreword xv 
Executive Summary
 

Clinicians and program administrators are increasingly aware of 

the important differences between men and women with regard to 

the physical effects of substance use and the specific issues related 

to substance use disorders. They are also recognizing that these 

differences have an impact on treatment—that gender does make 

a difference. When women’s specific needs are addressed from the 

outset, improved treatment engagement, retention, and outcomes are 

the result. 

This TIP endorses a biopsychosociocultural framework based 

on clinical practice and research centered on women. By placing 

emphasis on the importance of context, many topics examine the 

role of factors that influence women’s substance use from initiation 

of use to engagement of continuing care treatment services, i.e., 

relationships, gender socialization, and culture. The knowledge and 

models presented here are grounded in women’s experiences, built on 

women’s strengths, and based on best, promising, or research-based 

practices. The primary goal of this TIP is to assist substance abuse 

treatment providers in offering effective, up-to-date treatment to 

adult women with substance use disorders. 

The TIP is organized into eight chapters. The following section 

summarizes the content of each chapter to present an overview of this 

publication. 

Creating the Context 

The consensus panel for this TIP proposes that substance abuse 

treatment for women be approached from a perspective that 

encompasses the contexts of women’s lives. These contexts include 

a woman’s social and economic environment; her relationships with 

family, extended family, and support systems; and the impact of 

gender and culture. As a framework to explore women’s substance 

use disorders, treatment needs, and treatment approaches, this TIP 

adopted two systemic models: Bronfenbrenner’s ecological model 

and CSAT’s Comprehensive Substance Abuse Treatment Model for 

Women and Their Children. Both models endorse the relevance 

and influence of multisystems and their bidirectional infl uence upon 

women’s lives. 

Executive Summary xvii 
What makes gender an important clinical issue 

in substance abuse treatment? Are there gender 

differences in the development and pattern of 

substance use disorders? Do these differences 

warrant specific treatment approaches? To 

date, there is considerable evidence denoting 

that gender differences do exist, and these 

differences begin with early risk factors for 

substance use and extend throughout the 

course of treatment and recovery. Grounded 

in research, this TIP begins with unique 

biopsychosocial and developmental issues 

of women that create or intensify gender 

differences across the continuum of care. 

Knowledge of these unique factors is essential 

for treatment providers to fully understand the 

contexts of women’s lives and their needs. 

Based on the premise and knowledge that 

women are biopsychosocially unique in ways 

that are relevant to substance use, substance 

use disorders, and substance abuse treatment, 

this consensus panel endorses core principles for 

gender responsive treatment for women, such 

as–– 

• 	Acknowledging the importance as well as 

the role of the socioeconomic issues and 

differences among women. 

• 	Promoting cultural competence specifi c to 

women. 

• 	 Recognizing the role as well as the 

significance of relationships in women’s lives. 

• 	Addressing women’s unique health concerns. 

• 	Endorsing a developmental perspective. 

• 	Attending to the relevance and infl uence of 

various caregiver roles that women often 

assume throughout the course of their lives. 

• 	 Recognizing that ascribed roles and 

gender expectations across cultures affect 

societal attitudes toward women who abuse 

substances. 

• 	Adopting a trauma-informed perspective. 

• 	 Using a strengths-based model for women’s 

treatment. 

• 	Incorporating an integrated and 

multidisciplinary approach to women’s 

treatment. 

• 	 Maintaining a gender responsive treatment 

environment across settings. 

• 	 Supporting the development of gender 

competency specific to women’s issues. 

Patterns of Use: From 


Initiation to Treatment
 

Numerous factors influence the reasons for 

initiation of substance use among women, and 

a number of these factors are more prevalent 

among women than men. Women often report 

that stress, negative affect, and relationships 

precipitate initial use. In fact, women are often 

introduced to substance use by a signifi cant 

relationship such as boyfriend, family member, 

or close friend. Though genetics also may be a 

significant risk factor for women, more research 

supports familial influence—a combination of 

genetic and environment effects. Less is known 

about familial influence of illicit drugs, but 

parental alcohol use increases the prevalence of 

alcohol use disorders among women by at least 

50 percent. Family of origin characteristics play 

a role too. Exposure to chaotic, argumentative, 

and violent households, or being expected to 

take on adult responsibilities as a child, are 

other factors associated with initiation and 

prevalence of substance use disorders among the 

female population. 

Women are signifi cantly infl uenced by 

relationships, relationship status, and the 

effects of a partner’s substance abuse. Women 

dependent on substances are more likely to have 

partners who have substance use disorders. 

At times, women perceive shared drug use 

with their partner as a means of connection 

or of maintaining the relationship. Often, 

rituals surrounding drug use are initiated by 

a male partner, and women bear more risk in 

contracting HIV/AIDS and hepatitis by sharing 

needles or having sexual relationships with men 

who inject drugs. Relationship status similarly 

influences use and potential development of 

substance use disorders. Marriage appears 

protective, whereas separated, never married, 

or divorced women are at greater risk for use 

and the development of substance use disorders. 

Relationship influence does not stop at the 

point of treatment entry; relationships also 

xviii Executive Summary 
signifi cantly influence treatment engagement, 

retention, and outcome among women. 

Other risk factors associated with initiation 

of use and the prevalence of substance use 

disorders include sensation-seeking, symptoms 

of depression and anxiety, posttraumatic stress 

and eating disorders, and difficulty in regulating 

affect. Women with a history of trauma, 

including interpersonal and childhood sexual 

abuse, are highly represented in substance abuse 

samples. In addition, sociocultural issues play a 

significant role across the continuum beginning 

with enhanced risk for substance use. Degree 

of acculturation, experiences of discrimination, 

and socioeconomic status are prominent risk 

factors from the outset but continue to infl uence 

women’s substance use, health status, treatment 

access, and help-seeking behavior. 

Among women, six patterns of substance use 

clearly emerge from empirical data. First, 

the gender gap is narrowing for substance use 

across ethnicities, particularly among young 

women. Second, women are more likely to be 

introduced to and initiate substance use through 

significant relationships, while marital status 

appears to play a protective role. Third, women 

accelerate to injecting drugs at a faster rate 

than men, and rituals and high-risk behaviors 

surrounding drug injection are directly 

influenced by significant relationships. Fourth, 

women’s earlier patterns of use (including age of 

initiation, amount, and frequency) are positively 

associated with higher risks for dependency. 

Next, women are more likely to temporarily 

alter their pattern of use in response to caregiver 

responsibilities. And last, women progress faster 

from initiation of use to the development of 

substance-related adverse consequences. 

Substance use is not as prevalent among women 

as it is among men, but women are as likely as 

men to develop substance use disorders after 

initiation. Women who are pregnant are likely to 

reduce or remain abstinent during pregnancy; 

however, continued use is associated with a wide 

range of issues and effects—from less prenatal 

care to potential irreparable harm to the child 

from fetal exposure. Among those entering treatment, women are more likely to report drug use 

as the main reason for admission. 

Physiological Effects of Alcohol, 

Drugs, and Tobacco on Women 

Women develop substance use disorders in 

less time than men. Some factors that either 

influence or compound the physiological effects 

of drugs and alcohol include ethnicity, health 

disparity, socioeconomic status, developmental 

issues, aging, and co-occurring conditions. 

Although research on the physiological 

effects of alcohol and illicit drugs on women 

is limited and often inconclusive, signifi cant 

differences have been found in the way 

women and men metabolize alcohol. Women 

have more complications and more severe 

problems from alcohol use than do men, and 

these complications and problems develop 

more rapidly. This phenomenon is known as 

“telescoping.” Complications include liver 

disease and other organ damage; cardiac-related 

conditions such as hypertension; reproductive 

consequences; osteoporosis; cognitive and other 

neurological effects; breast and other cancers; 

and greater susceptibility and progression of 

infections and infectious diseases, including 

HIV/AIDS and hepatitis C virus (HCV). 

Although many physiological effects of licit and 

illicit drugs have not been well studied, research 

has shown that abuse of substances such as 

stimulants, opioids, and some prescription 

(e.g., anxiolytics, narcotic analgesics) and 

over-the-counter (e.g., laxatives, diuretics, 

diet pills) drugs causes adverse effects on 

women’s menstrual cycles and gastrointestinal, 

neuromuscular, and cardiac systems, among 

others. With regard to nicotine use, women 

who smoke increase their risk of lung cancer. 

Currently, cancer is the second leading cause 

of death among women, with mortality rates 

higher for lung cancer than breast cancer. 

Other physiological consequences of tobacco 

use include, but are not limited to, increased 

risks for peptic ulcers, Crohn’s disease, estrogen 

deficiencies, strokes, and atherosclerosis. 

Women who smoke are more likely to have 

chronic obstructive pulmonary disease and 

coronary heart disease. 

Women who use alcohol, drugs, or tobacco 

while pregnant or nursing expose their fetuses 

Executive Summary xix 
or infants to these substances as well. The most 

thoroughly examined effect of alcohol on birth 

outcomes is fetal alcohol syndrome, which 

involves growth retardation, central nervous 

system and neurodevelopmental abnormalities, 

and craniofacial abnormalities. Alcohol and 

drug use by pregnant women is associated with 

many complications, including spontaneous 

abortion, prematurity, low birth weight, 

premature separation of the placenta from the 

uterine wall, neonatal abstinence syndrome, 

and fetal abnormalities. Likewise, women who 

are pregnant and use tobacco are more likely to 

deliver premature and low birth weight infants. 

Screening and Assessment
 

Understanding the extent and nature of 

a woman’s substance use disorder and its 

interaction with other areas of her life is 

essential for accurate diagnosis and successful 

treatment. This understanding can be acquired 

through screening and assessment. Screening is 

typically a brief process for identifying whether 

certain conditions may exist and usually involves 

a limited set of questions to establish whether 

a more thorough evaluation and referral(s) 

are needed. Sociocultural factors—ethnicity, 

culture, acculturation level, language, and 

socioeconomic status—are particularly 

relevant in screening and assessment selection, 

in determining the appropriateness of the 

instruments, and in interpreting the subsequent 

results. Sociocultural and socioeconomic 

characteristics of the client can affect testing 

expectations and behavior of both the 

counselor and client during the screening and 

assessment process; e.g., the client’s distrust and 

subsequent reluctance in the testing process or 

the counselor’s expectation that a woman with 

lower socioeconomic status will have a positive 

screening for alcohol or drug use. 

For women, general alcohol and drug screening 

that determines current or at-risk status for 

drug and alcohol use during pregnancy is 

essential. However, healthcare professionals 

sometimes overlook the necessity of drug 

and alcohol screening for older, Asian, and/ 

or middle- and upper-class women who are 

pregnant. Screening is more likely based 

on preconceived beliefs concerning greater 

prevalence of substance abuse among women 

from diverse ethnic groups. Counselors and 

intake personnel may also alter their behavior 

when working with diverse populations, such as 

eye contact, body language, and communication 

styles, that ultimately affect clients’ responses 

and trust in the screening process. 

Other screenings involve the determination of 

co-occurring risks, conditions, or disorders, 

including general mental disorders, mood 

and anxiety disorders, risk of harm to self 

or others, history of childhood trauma and 

interpersonal violence, and eating disorders. 

Considering women’s likely involvement with 

health care providers, screening for substance 

use and abuse should be a standard practice. 

Yet, the implementation of screening, regardless 

of setting, is only as good as the protocol in 

providing feedback, referral, and followup. Screening is not an intervention. What 

makes the difference is how a woman’s positive 

endorsement of screening questions leads to 

feedback, referral, further assessment, and 

intervention, if warranted. 

The difference between screening and 

assessment is that assessment examines 

several domains in a client’s life in detail so 

that diagnoses can be made for substance use 

disorders and possible co-occurring mental 

disorders. Assessment is an ongoing process 

in which the counselor forms an increasingly 

clearer picture of the client’s issues, how they 

can best be addressed, and how the client is 

changing over time. An assessment interview, 

such as a structured psychosocial interview, 

an unstructured psychosocial and cultural 

history, and/or the Addiction Severity Index, 

needs sufficient time to complete. The degree 

to which it is possible or advisable to probe in 

depth in different areas of functioning depends 

on the individual issues, the needs of the woman, 

the complexity of her issues, and the level 

of rapport between the client and clinician. 

Equally important, assessment processes should 

explore coping styles, strengths, and available 

support systems. An assessment process would 

xx Executive Summary 
not be complete without a health assessment and 

medical examination. 

In sum, screening and assessment for women 

must be approached from a perspective that 

allows for and affirms cultural relevance and 

strengths. Whenever possible, instruments that 

have norms established for specifi c population 

groups should be used. Counselors’ sensitivity to 

the clients’ cultural values and beliefs, language, 

acculturation level, literacy level, and emotional 

ability to respond facilitates the assessment 

process and helps women engage in treatment. 

Treatment Engagement, 


Placement, and Planning
 

Women face many obstacles and challenges 

in engaging in treatment services: lack of 

collaboration among social service systems, 

limited options for women who are pregnant, 

lack of culturally congruent programming, 

few resources for women with children, fear 

of loss of child custody, and the stigma of 

substance abuse. On one hand, intake personnel 

and counselors can help women tackle and 

overcome personal barriers to treatment (such 

as issues of motivation and shame); yet, on the 

other hand, programming and administrative 

policies must address obstacles surrounding 

program structure, interagency coordination, 

and service delivery to improve treatment 

engagement. In recent years, more effective 

engagement strategies have been implemented. 

Outreach services, pretreatment intervention 

groups, and comprehensive and coordinated 

case management can effectively address the 

numerous barriers and the array of complex 

problems that women often express in their role 

as caregivers. 

Treatment placement decisions are based not 

only on the woman’s individual needs and 

the severity of her substance use disorder but 

also on the treatment options available in the 

community, her financial circumstances, and 

available healthcare coverage. To determine 

treatment placement, the American Society 

of Addiction Medicine’s Patient Placement 

Criteria, Second Edition Revised (ASAM’s PPC2R), are used widely, and the levels determined 

by these criteria are useful to standardize 

treatment placement. To date, empirical 

literature supporting specific placement criteria 

for women is limited. The treatment levels 

suggested by the consensus panel and supported 

by ASAM criteria include pretreatment or 

early intervention; detoxifi cation; outpatient 

treatment; intensive outpatient treatment 

(IOT); residential and inpatient treatment; 

and medically managed, intensive inpatient 

treatment. Specific placement criteria must also 

account for pregnancy, child placement, and 

children services. Treatment services for women 

must extend beyond standard care to address 

specific needs for women, pregnant women, and 

women with children such as medical services, 

health promotion, life skills, family- and childrelated treatment services, comprehensive and 

coordinated case management, and mental 

health services. 

When clients participate fully in decisions 

related to treatment, they are more likely to 

understand the process and develop realistic 

expectations of treatment. Active involvement 

of clients in all aspects of treatment planning 

and placement significantly contributes to both 

recovery and empowerment and is essential to 

the development of meaningful, effective services 

for women. 

Substance Abuse Among 

Specific Population Groups 

and Settings 

Women who are of different racial and ethnic 

groups, different sexual orientations, in the 

criminal justice system, living in rural areas, 

older, and who speak languages other than 

English are among the population groups that 

may experience unique challenges that affect 

their substance use or abuse and its treatment. 

The risk for substance abuse and its 

consequences and optimal processes for 

treatment and recovery differ by gender, 

race, ethnicity, sexual orientation, and other 

factors. The complex interplay of culture and 

Executive Summary xxi 
health—as well as the influence of differing 

attitudes toward, definitions of, and beliefs 

about health and substance use among cultural 

groups—affects the psychosocial development of 

women and their alcohol, drug, and tobacco use 

and abuse. Women’s risks for substance abuse 

are understood best in the social and historical 

context in which the influences of gender, race 

and ethnicity, education, economic status, age, 

geographic location, sexual orientation, and 

other factors converge. Understanding group 

differences across segments of the population of 

women is critical to designing and implementing 

effective substance abuse treatment programs 

for women. 

Training helps staff members recognize the 

individual and group strengths and resiliency 

factors that can assist women from diverse 

identity groups in recovery. These include 

beliefs regarding health care and substance 

abuse; the value the individual or identity group 

places on family and spirituality; the effects of 

group history on current behaviors; how women 

are socialized in a particular culture; and the 

flexibility of gender norms, communication 

styles, rituals, the status of women, the stigma 

the group or individual faces, and attitudes 

toward self-disclosure and help-seeking 

behavior. 

Substance Abuse 

Treatment for Women 

Gender does not appear to predict retention 

in substance abuse treatment. Women are 

as likely as men to stay in treatment once 

treatment is initiated. Factors that encourage a 

woman to stay in treatment include supportive 

therapy, a collaborative therapeutic alliance, 

onsite child care and children services, and 

other integrated and comprehensive treatment 

services. Sociodemographics also play a role 

in treatment retention. Studies suggest that 

support and participation of signifi cant others, 

being older, and having at least a high school 

education are important factors that improve 

retention. Criminal justice system or child 

protective service involvement also is associated 

with longer lengths of treatment. Women are 

more likely to stay in treatment if they have had 

prior successful experiences in other life areas 

and possess confidence in the treatment process 

and outcome. Although pregnancy may motivate 

women in initiating treatment, studies suggest 

that pregnant women do not stay in treatment 

as long and that retention may be signifi cantly 

affected by stage of pregnancy and the presence 

of co-occurring psychiatric disorders. 

Limited research is available highlighting 

specific therapeutic approaches for women 

outside of trauma-informed services. In recent 

years, more attention has been given to effective 

women’s treatment programming across systems 

with considerable emphasis on integrated care 

and the identification of specifi c treatment 

issues and needs for women. Gender specifi c 

factors that influence the treatment process 

and recovery evolve around the importance of 

relationships, the influence of family, the role of 

substance use in sexuality, the prevalence and 

history of trauma and violence, and common 

patterns of co-occurring disorders. Among 

women with substance use and co-occurring 

mental disorders, diagnoses of posttraumatic 

stress and other anxiety disorders, postpartum 

depression and other mood disorders, and 

eating disorders are more prevalent than among 

men who are in treatment for substance use 

disorders. Consequently, clinical strategies, 

treatment programming, and administrative 

treatment policies must address these issues to 

adequately treat women. Likewise, women often 

need clinical and treatment services tailored 

to effectively address pregnancy, child care, 

children services, and parenting skills. 

Recovery Management 

and Administrative 

Considerations 

Empirical data suggest that women are as likely 

as men to attend continuing care services. 

Transition from a more intensive level of care 

to less intensive services has proven to be 

challenging for all clients, but evidence suggests 

that women will continue with services if they 

xxii Executive Summary 
stay within the same agency and/or effort 

is made to connect them to the new service 

provider prior to transition. 

Gender does not consistently predict treatment 

outcome. For example, women have comparable 

abstinent rates with men and are as likely to 

complete treatment. Even so, women are more 

likely to have positive treatment outcomes in the 

following ways: less incarceration, higher rates 

of employment, and more established recoveryoriented social support systems. Women and 

men do not differ in relapse rates. It is more 

likely that individual characteristics hold the 

key in determining who may be a greater risk 

for relapse. However, there is a delineation 

of the types of risks and triggers that make 

women versus men more vulnerable to relapse, 

and women exhibit different emotional and 

behavioral responses during and after relapse. 

Women report more interpersonal problems and 

strong negative affect, including symptoms of 

depression, severe traumatic stress reactions to 

early childhood trauma, and low self-worth, as 

precipitants of relapse. They also display a lack 

of coping skills, greater difficulty in severing 

their connections with individuals who use, and 

a failure in establishing new recovery-oriented 

friends. Conversely, women who relapse are 

more likely to seek help and have shorter 

relapse episodes. 

Other considerations in providing treatment 

to women involve programmatic and 

administrative issues. First, full participation 

of clients as partners in treatment is important, 

and both the program and client will benefi t 

if they are involved in program development 

and serve in an advisory capacity. Programs 

will likely improve the quality of services and 

clients will benefit from an increase in selfefficacy, the attainment of specific skills, and a 

reduced stigma from substance abuse treatment. 

Gender-responsive treatment involves a safe 

and non-punitive atmosphere, where staff hold 

a hopeful and positive attitude toward women 

and show investment in learning about women’s 

experiences, treatment needs, and appropriate 

interventions. Administrators need to invest 

in staff training and supervision and show a 

commitment to training beyond immediate 

services. Training should include other social 

and healthcare facilities and personnel within 

the community to enhance awareness, identify 

women with substance use disorders, and 

increase appropriate referrals. As research, 

programming, and clinical experience expand 

along gender lines in substance abuse treatment, 

clinicians and administrators alike will have 

considerable opportunities in adapting new 

standards of care for women. 

Executive Summary xxiii 
In This
 

Chapter
 

Creating the Context
 

Gender Responsive 


Treatment Principles
 

Women’s 


Biopsychosocial 


Uniqueness
 

Organization 


of this TIP
 

1 Creating the Context
 

Overview 

Women with substance use disorders have unique biopsychosocial 

needs that should be addressed if their treatment is to be successful. 

This TIP examines the current state of women’s substance abuse 

treatment needs, approaches, and experience; highlights promising 

strategies and best practices for treatment counselors working with 

female clients; and explores evidence-based research and clinical 

issues that affect treatment for women. The primary goals of this TIP 

are to help substance abuse treatment counselors and administrators 

provide effective treatment for women and to assist clinicians in 

equipping their female clients with the tools they need to maintain 

recovery. 

Following is an introduction to many of the themes and issues 

discussed in greater depth in later chapters. This chapter presents a 

guiding framework for treatment of women who have substance use 

disorders. It highlights the multiple contexts of women’s lives and 

treatment issues, provides gender responsive principles of treatment, 

and presents the unique biopsychosocial needs that characterize 

the issues women face in treatment. The chapter concludes with a 

discussion on guidelines for readers and definitions of terms and 

concepts used in this TIP. 

Creating the Context 

According to the Substance Abuse and Mental Health Services 

Administration’s (SAMHSA’s) National Survey on Drug Use and 

Health (NSDUH), 6.2 percent of females ages 12 and older were 

classified with substance dependence or abuse in 2004, but only 

0.9 percent of females received treatment in 2004 (SAMHSA 2005). 

Creating the Context 1 
The medical, social, emotional, and fi nancial 

consequences and costs of these disorders to 

women’s families and society are enormous. 

By and large, women with substance use 

disorders must find a way to support themselves 

and their children, often with little experience 

or education and few job skills. They frequently 

have to overcome feelings of guilt and shame 

for how they treated their children while 

abusing substances. When a woman becomes 

pregnant, her motivation to seek treatment 

may rise greatly. However, pregnancy itself can 

be a barrier to treatment because substance 

abuse treatment programs are not always able 

to admit pregnant women or to provide the 

services required, such as medically indicated 

bed rest, transportation to prenatal care, and 

nutritious meals (Jessup et al. 2003). Some 

women fear the negative consequences that will 

result if their substance abuse becomes known. 

In many States, pregnant and parenting women 

can be reported to child protective services, lose 

custody of their children, or be prosecuted for 

using drugs. On top of additional healthcare 

needs, substance use during pregnancy confers 

stigma and shame, which may create another 

challenge in treatment. 

A high proportion of women with substance 

use disorders have histories of trauma, often 

perpetrated by persons they both knew and 

trusted. A woman might have experienced 

sexual or physical abuse or witnessed violence 

as a child. She may be experiencing domestic 

violence such as battering by a partner or 

rape as an adult (Finkelstein 1994; Young and 

Gardner 1997). These traumas contribute to the 

treatment needs for women. 

The societal stigma toward women who abuse 

substances tends to be greater than that toward 

men, and this stigma can prevent women from 

seeking or admitting they need help. Women 

who use alcohol and illicit drugs often have 

great feelings of shame and guilt, have low levels 

of self-esteem and self-efficacy, and often are 

devalued or disliked by other women. These 

feelings make it difficult for women to seek 

help or feel that they deserve to be helped— 

creating yet more treatment needs that must be 

addressed. Gender role expectations in many 

cultures result in further stigmatization of 

substance use; additional challenges face women 

who are of color, disabled, lesbians, older, and 

poor. 

Over the last decade, women with substance use 

disorders have increasingly been the subject of 

scientific study. Studies have explored the effects 

of alcohol and illicit drugs on pregnancy in 

greater detail, best practices in substance abuse 

treatment for women, the impact of trauma 

and the need for trauma-informed services, 

and the importance of incorporating a gender 

responsive framework. More recently, research 

is burgeoning in the area of outcome variables, 

relapse prevention, women and child services, 

and specific treatment approaches. This TIP 

seeks to help the substance abuse treatment 

system lower barriers, improve treatment, and 

assist clinicians in providing their female clients 

with the tools needed to maintain recovery. 

Improved collaboration within the current 

system of health care and social services will 

result in more comprehensive and responsive 

care for women in recovery. 

Sociocultural Context 

The consensus panel for this TIP approached 

substance abuse treatment for women from 

a perspective that encompasses the multiple 

contexts of women’s lives. This TIP provides 

a systemic framework for looking at women 

with substance use disorders, and uses 

Bronfenbrenner’s ecological model (1989), 

where women are engaged in multisystems and 

relationships that maintain a bidirectional 

influence—the systems and relationships 

influence the woman with a substance use 

disorder and the woman, along with the 

impact of her substance use, infl uences her 

relationships and the systems that interact with 

her. Figure 1-1 depicts a woman as the center of 

a circle, surrounded by other concentric rings. 

Each ring represents a different system with 

the closest adjacent ring representing her most 

immediate relationships––the microsystem. 

The following ring, the mesosystem, represents 

the interrelationships between her immediate 

relationships and systems; e.g. the interaction 

2 Creating the Context 
between her family and school, the potential 

influence or conflict between her substance using 

peer group and her family. Next, the exosystem 

represents larger systems that directly infl uence 

the woman but where the woman has no direct 

active role; e.g., county funding for treatment or 

State and Federal laws pertaining to sentencing 

or child protective services. The macrosystem 

is the largest system that involves cultural 

values and beliefs, gender socialization, political 

ideologies, etc. Each system is infl uenced by 

chronology, or life events. These events, either 

normative or non-normative individual events 

at specific developmental periods or historical 

events, can have significant impact and infl uence 

on further development, treatment needs and 

recovery, and ultimately interactions among all 

systems. 

Using a systems approach is appropriate 

regardless of gender, yet it is a vital framework 

for understanding women’s treatment needs 

and the impact of substance use on their 

relationships and caregiving roles. Consistent 

Creating the Context 3 

Figure 1-1 

A Woman’s Life in Context 

Source: Bronfenbrenner 1989
 
with Bronfenbrenner’s model, this TIP uses 

SAMHSA’s Center for Substance Abuse 

Treatment’s (CSAT’s) Comprehensive Substance 

Abuse Treatment Model for Women and 

Their Children as the keystone in addressing 

women’s treatment needs and services. Figure 

1-2 highlights the four broad interrelated 

elements of CSAT’s comprehensive model of 

care including clinical treatment services, 

clinical support services, community support 

services, and cultural competence. For more 

in-depth information about this model, refer to 

Appendix B. This model is an update of a model 

published in 1994 in Practical Approaches in 

the Treatment of Women Who Abuse Alcohol and 

Other Drugs (CSAT 1994a). 

Gender Responsive 


Treatment Principles
 

The principles articulated by the consensus 

panel, which serve as the TIP’s conceptual 

framework, are explained below. Each principle 

is derived from research that highlights the 

distinctive characteristics and biopsychosocial 

issues associated with women in general and 

specific to women with substance use disorders. 

• 	Acknowledge the importance and role 

of socioeconomic issues and differences 

among women. Biological, cognitive– 

behavioral, and psychological dimensions 

of women’s substance use and abuse should 

be framed in their socioeconomic contexts 

Figure 1-2 

Interrelated Elements in the Comprehensive Treatment Model 

4 Creating the Context 
including, but not limited to, employment, 

educational status, transportation, housing, 

literacy levels, and income. 

• 	Promote cultural competence specifi c 

to women. Treatment professionals and 

staff must understand the worldviews and 

experiences of women from different ethnic 

and cultural backgrounds, as well as the 

interaction among gender, culture, and 

substance use to provide effective substance 

abuse treatment. In addition, effective 

treatment will depend equally on attention 

and sensitivity to the vast diversity among 

the female population, including overlapping 

identities of race, class, sexual orientation, 

age, national origin, marital status, disability, 

and religion. 

• 	Recognize the role and signifi cance 

of relationships in women’s lives. The 

relational model recognizes the centrality of 

relationships or connections in women’s lives 

and the importance of those relationships 

with respect to alcohol, tobacco, and drug 

use. While substance use may initially play 

an integral role in making or maintaining 

connections in relationships, the relational 

approach views the development of substance 

use disorders as a “disconnection” and 

stresses the development and repair of 

connections to others, oneself, one’s beliefs, 

and one’s culture as critical for recovery. 

The relational model takes a family-focused 

perspective, using a broad defi nition of 

family as those individuals a woman views 

as her significant support system. In this 

model, a woman’s children are included in 

her treatment, and prevention and treatment 

services must be provided directly to her 

children and family. 

• 	Address women’s unique health concerns. 

Women possess distinctive risk factors 

associated with onset of use, have greater 

propensity for health-related consequences 

from drug and alcohol consumption, exhibit 

higher risks for infectious diseases associated 

with drug use, and display greater frequency 

of various co-occurring disorders. Moreover, 

women who abuse substances are more 

likely to encounter problems associated with 

reproduction, including fetal effects from 

substance use during pregnancy, spontaneous 

abortion, infertility, and early onset of 

menopause. Substance abuse treatment needs 

to address women’s unique health concerns 

throughout the course of treatment. 

• 	Endorse a developmental perspective. 

In general, women experience unique life 

course issues. Specific to women who abuse 

substances, these life course issues, along 

with developmental milestones, impact their 

patterns of use, engagement in treatment, 

and recovery. Substance use and abuse affect 

women differently at different times in their 

lives. It is important to consider age-specifi c 

and other developmental concerns starting 

with the assessment process and continuing 

through continuing care and long-term 

recovery. 

• 	Attend to the relevance and infl uence 

of various caregiver roles that women 

often assume throughout the course 

of their lives. Regardless of substance 

abuse, women are more likely to assume 

primary caregiving responsibilities for 

their children, grandchildren, parents, and 

other dependents. These roles may heavily 

influence a woman’s willingness to seek help 

for substance abuse, and also may interfere 

with her ability to fully engage in the 

treatment process or to adhere to treatment 

recommendations. 

• 	Recognize that ascribed roles and gender 

expectations across cultures affect societal 

attitudes toward women who abuse 

substances. Whether or not a woman neglects 

her roles as a caregiver, engages in alcohol 

or drug-induced sexual activity, continues 

to use despite pregnancy, or uses sex to 

secure her next supply of drugs or alcohol, 

women with substance use disorders are 

significantly stigmatized by societal attitudes 

and stereotypes of women who drink and use 

drugs. As a result, women may experience 

feelings of shame associated with their use 

and the consequences of their use. 

• 	Adopt a trauma-informed perspective. 

Current and past violence, victimization, 

and abuse greatly affect many women 

Creating the Context 5 
who abuse alcohol and drugs. Substance 

abuse treatment approaches need to help 

women find safety, develop effective coping 

strategies, and recover from the effects of 

trauma and violence. 

• 	Utilize a strengths-based model for 

women’s treatment. A strengths-based 

approach builds on the woman’s strengths 

and uses available resources to develop 

and enhance resiliency and recovery skills, 

deepen a sense of competency, and improve 

the quality of her life. These strengths 

may include personality traits, abilities, 

knowledge, cultural values, spirituality, and 

other assets; while resources may involve 

supportive relationships, environments, and 

professional support. 

• 	Incorporate an integrated and 

multidisciplinary approach to women’s 

treatment. Treatment needs to integrate 

current knowledge, research, theory, 

experience, and treatment models from 

diverse disciplines critical to understanding 

women and substance abuse treatment. 

In addition to incorporating and blending 

information from the mental health, women’s 

health, and social and behavioral sciences 

fields, treatment providers must network 

and collaborate with other agencies to 

provide comprehensive case management and 

treatment planning to address the complexity 

of biopsychosocial and cultural issues that 

women may exhibit throughout treatment. 

• 	Maintain a gender-responsive treatment 

environment across settings. Effective 

treatment for women begins with a 

collaborative environment that is nurturing, 

supportive, and empowering. Women with 

substance use disorders are more likely 

to remain in a treatment setting that feels 

familiar and safe, includes their children, 

utilizes proactive case management, and 

fosters the development of supportive 

relationships across the continuum of care. 

• 	Support the development of gendercompetency specific to women’s issues. 

Administrative commitment and vigilance 

is needed to ensure that staff members 

are provided gender-specific training and 

supervision to promote the development of 

gender competency for women. 

Women’s Biopsychosocial 

Uniqueness 

There is notable evidence to suggest that gender 

does make a difference. Whether examining risk 

factors to relapse potential, biological aspects to 

psychological issues, or treatment engagement 

to attrition rates, empirical evidence suggests 

that gender differences do exist in substance use 

disorders. For women, unique biopsychosocial 

and developmental issues create or intensify 

these differences, which require specifi c 

treatment needs across the continuum of care of 

substance use disorders. 

This TIP is based on the premise that women 

are biopsychosocially unique in ways relevant 

to substance use, substance use disorders, and 

the treatment of these disorders. Specifi cally, 

this TIP takes the following position: There 

are biopsychosocial factors that may affect 

a significant proportion of women across 

the continuum of substance abuse services. 

The knowledge of these factors will likely 

assist the substance abuse counselor in better 

understanding and responding to the treatment 

needs of female clients. 

Not only do women face numerous obstacles to 

entering and remaining in treatment, they also 

have specific needs while in treatment. Some 

obstacles stem from the frequently low economic 

status of women, the likelihood that they are 

custodial parents, the greater incidence of 

trauma and violence in female clients, and the 

societal stigma of substance abuse. 

Additional treatment needs stem from a 

greater incidence of co-occurring mental 

disorders among female clients, and the 

growing realization that women respond better 

to treatment approaches that are supportive 

rather than confrontational and that promote 

relationships and positive connections among 

other clients in recovery and treatment 

providers. 

6 Creating the Context 
Supported by research, this section highlights 

the biopsychosocial uniqueness of women 

and the impact that these characteristics may 

have on the onset of use, the development and 

progression of substance abuse and dependence, 

and the treatment of substance use disorders. 

The unique biopsychosocial characteristics 

are divided into three segments: biological and 

psychological, social, and developmental. This 

section does not focus on specific populations or 

on biopsychosocial, cultural, or developmental 

issues that are common in both men and women. 

Biological and Psychological 

Differences between women and men in 

genetics, physiology, anatomy, and sociocultural 

expectations and experiences lay the 

foundation—that women have unique health 

concerns related to substance use disorders as 

well as elevated risk for certain co-occurring 

physical and mental issues or disorders. This 

segment highlights and outlines the unique 

physiological and psychological issues that need 

attention across the continuum of care. 

1. Women have different physical responses 

to substances. 

Women have different physical responses to 

substances and typically display a quicker 

progression from initial use to the development 

of health-related problems (Antai-Otong 2006; 

Mann et al. 2005). Women become intoxicated 

after drinking smaller quantities of alcohol than 

men. For women who drink, they are affected 

more by alcohol consumption due to higher 

blood alcohol concentrations, proportionately 

more body fat, and a lower volume of body 

water to dilute alcohol. 

Women develop substance use disorders and 

health-related problems in less time than do 

men, and this effect is known as telescoping. 

While research has studied the differences 

in metabolism with alcohol intake, studies 

highlighting gender differences with illicit drugs 

is limited (Brady and Ashley 2005; Greenfi eld 

and O’Leary 2002; Sherman 2006). A few 

preliminary studies (Katz et al. 2004) have 

identified perceptual differences between men 

and women asserting that women report more 

intense or positive effects; yet fi ndings across 

studies are inconclusive. Chapter 3 of this 

TIP provides a review of physical responses to 

substance use, beginning with the factors that 

influence these reactions including, but not 

limited to, ethnicity, acculturation, and aging. 

2. Women with substance use disorder have 

greater susceptibility to as well as earlier 

onset of serious medical problems and 

disorders. 

In general, women develop alcohol-related 

physical health problems at lower doses and 

over shorter periods of time than do men. Less 

evidence is available on gender differences 

regarding the effects and health consequences of 

other illicit drug use, but women also appear to 

have higher rates of health problems resulting 

from other substances (Sherman 2006). From 

moderate to heavy use, drugs and alcohol 

consumption increase specific health risks and 

physical disorders among women. 

Alcohol consumption signifi cantly increases 

risk for breast and other cancers (Bagnardi 

et al. 2001; Key et al. 2006; Tiemersma et al. 

2003), osteoporosis in premenopausal women 

(Sampson 2002), peripheral neuropathy, 

and cognitive impairments (Flannery et 

al. 2007; Sohrabji 2002). Overall, women 

develop cirrhosis and heart muscle and nerve 

damage with fewer years of heavy drinking in 

comparison to men. Likewise, illicit drug use is 

associated with greater risk for liver and kidney 

diseases, bacterial infections, and opportunistic 

diseases. Chapter 3 presents an overview of the 

physiological effects and consequences of alcohol 

and drug use, including nicotine, among women. 

3. Women who abuse substances have specifi c 

health issues and medical needs related to 

gynecology. 

Routine gynecological care is fundamental to 

the prevention or early detection of a variety 

of serious health problems among women with 

substance use disorders, including cervical, 

breast, and other cancers; HIV/AIDS; and 

other infectious diseases. Evidence supports 

the havoc substances play on reproductive 

Creating the Context 7 
processes, such as the role of heavy alcohol use 

on infertility and drug use on menstrual cycles 

(Lynch et al. 2002; Reynolds and Bada 2003; 

Tolstrup et al. 2003). Even though gynecological 

concerns are frequently one of the main health 

concerns identified by women in substance abuse 

treatment, many young and low-income women 

have never had a gynecological examination. 

Moreover, women over 40 with substance use 

disorders are less likely to have received a 

mammogram than other women of similar age 

(Carney and Jones 2006). Refer to chapter 3 for 

more information on gynecological consequences 

related to substance use disorders. 

4. In treating women of childbearing age who 

have a substance use disorder, pregnancy is 

a signifi cant concern. 

Women who are abusing or are dependent on 

alcohol or other drugs may not realize they are 

pregnant. At times, women may mistakenly 

associate early signs of pregnancy as symptoms 

related to use or withdrawal from substances. 

Often, women who are pregnant and using 

alcohol and illicit drugs do not begin prenatal 

care until well into their pregnancies. Some of 

the most negative effects of substance use on the 

developing embryo can occur in the fi rst weeks 

of pregnancy. 

Adequate prenatal care often defi nes the 

difference between routine and high-risk 

pregnancy and between good and bad pregnancy 

outcomes. Timely initiation of prenatal care 

remains a problem nationwide, and it is 

overrepresented among women with substance 

use disorders. In part, the threat of legal 

consequences for using during pregnancy and 

limited substance abuse treatment facilities 

(only 14 percent) that offer special programs 

for pregnant women (SAMHSA 2007) are key 

obstacles to care. 

Numerous medical concerns can result from 

substance use during pregnancy as well as from 

detoxification and the medications used to treat 

substance use disorders. Thus, identifi cation, 

comprehensive case management, and integrated 

services are essential in addressing these 

significant threats. The following chapters 

provide information on negative consequences 

of alcohol and drug use during pregnancy 

(chapter 3), specific screening questions and 

tools (chapter 4), engagement strategies and 

programming for pregnant women (chapter 5), 

and retention and review of treatment issues 

and needs for pregnant women with substance 

use disorders, including co-occurring disorders 

(chapter 7). 

5. Women who abuse substances are more 

likely than other women to have cooccurring disorders. 

In general, women with substance use disorders 

are more likely to meet diagnostic criteria for 

mood disorders specific to depressive symptoms, 

agoraphobia with or without panic attacks, 

posttraumatic stress, and eating disorders 

(Hudson et al. 2007; Piran and Robinson 2006; 

Tolin and Foa 2006). For women, literature 

suggests that the onset of psychiatric disorders 

is apt to precede substance use disorders. For 

instance, women who experience depression 

are more prone to develop alcohol problems 

after their first depressive episode (Caldwell et 

al. 2002; Wang and Patten 2002). Chapter 2 of 

this TIP addresses risk factors for substance 

use disorders, including the role of other 

psychological disorders. Chapter 4 offers 

screening tools to help counselors identify the 

need for further assessment due to presenting 

psychological symptoms. Chapter 7 identifi es 

treatment needs and strategies for the more 

prevalent psychological symptoms and disorders 

among women with substance use disorders, 

including trauma, posttraumatic stress and 

other anxiety disorders, and mood and eating 

disorders. 

6. Women who have substance use disorders 

are more likely to have been physically 

or sexually traumatized and subjected to 

interpersonal violence. 

A high proportion of women with substance 

use disorders have histories of trauma, often 

perpetrated by persons they both knew and 

trusted. These women may have experienced 

sexual or physical abuse, domestic violence, 

or witnessed violence as a child. Studies have 

8 Creating the Context 
consistently found that rates of sexual abuse 

in both childhood and adulthood are higher 

for women than for men, and that a lifetime 

history of sexual abuse ranges from 15 to 25 

percent (Leserman 2005; Tjaden and Thoennes 

1998). Similarly, prevalence of lifetime domestic 

violence among women in the United States 

ranges from 9 to 44 percent, depending on the 

employed definition of domestic violence in each 

study (for review, see Thompson et al. 2006; 

Wilt and Olson 1996). While race/ethnicity is 

not generally associated with interpersonal 

violence, lower socioeconomic status appears to 

be associated with greater prevalence. 

Women who have been abused as children are 

more likely to report substance use disorders 

as adults (Kendler et al. 2000). In a large study 

of female twins (n=3,536), childhood sexual 

abuse was associated with a greater likelihood 

of lifetime alcohol use, having the first drink at 

an early age, and alcohol dependence (Sartor 

et al. 2007). Likewise, physical and sexual 

dating violence were found to be “signifi cant 

independent predictors of substance use” in 

other research (Silverman et al. 2001). Among 

women seeking treatment for crack/cocaine 

abuse/dependence, a history of sexual trauma 

was associated with a greater number of health 

issues related to substance use, dependence on 

a greater number of substances, and a greater 

number of substance abuse treatment episodes 

(Young and Boyd 2000). In a study focused on 

the severity of childhood trauma among men 

and women who were dependent on cocaine, 

only a history of childhood trauma among 

women created a greater susceptibility to relapse 

and escalation in use after relapse (Hyman et al. 

2008). 

Numerous studies on interpersonal violence 

have found a similar reciprocal relationship 

between substance abuse and domestic violence 

(Kilpatrick et al. 1997; Swan et al. 2000; 

Tjaden and Thoennes 1998, 2000, 2006). Rates 

of partner abuse appear highest for women 

who use cocaine/crack (Swan et al. 2000) or 

methamphetamine (Cohen et al. 2003). However, 

women with substance use disorders and a 

history of physical abuse (from a known person, 

not necessarily a partner) are more likely to 

enter substance abuse treatment than women 

with substance use disorders who don’t have 

such a history (Walton-Moss and McCaul 2006). 

Clinical issues related to childhood sexual and 

physical abuse, interpersonal violence, and 

trauma are addressed throughout this TIP. More 

specific information is covered in the following 

chapters: 

 Chapter 2 addresses risk factors (including 

interpersonal violence, sexual abuse, 

and other traumas) associated with the 

development of substance use disorders. 

 Chapter 4 provides general screening and 

assessment guidelines, including tools for 

sexual victimization, childhood abuse, and 

interpersonal violence. 

 Chapter 7 highlights the treatment needs and 

interventions for these specifi c populations. 

For more comprehensive reviews of domestic 

violence and child abuse, refer to TIP 25 

Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b); TIP 36 Substance Abuse 

Treatment for Persons with Child Abuse and 

Neglect Issues (CSAT 2000b); and the planned 

TIP Substance Abuse and Trauma (CSAT in 

development h). 

Social 

1. Significant relationships and family history 

play an integral role in the initiation, 

pattern of use, and continuation of 

substance abuse for women. 

From a sociocultural perspective, women (more 

than men) tend to define themselves in terms of 

their webs of social relationships and obligations. 

Relationships with others have special 

significance for many women. Hence, family 

history may have a more profound effect on 

initiation of use among women than men. Women 

with alcohol use disorders are also more likely 

than men to report having had alcohol dependent 

parents, other alcohol dependent relatives, and 

dysfunctional family patterns (Jennison and 

Johnson 2001; Nelson-Zlupko et al. 1995). 

Creating the Context 9 
Women are more likely to be introduced to and 

initiate alcohol and drug use through signifi cant 

relationships including boyfriends, spouses, 

partners, and family members. This infl uence 

does not stop with initiation; it extends to 

greater use and higher incidence of substance 

use disorders when they have partners who 

abuse substances (Klein et al. 2003). In 

comparison to men, women with substance 

use disorders are more likely to have intimate 

partners who also have substance use disorders 

(Brady and Ashley 2005; Lex 1991; Riehman 

et al. 2003; Wright et al. 2007). In this TIP, 

chapter 2 addresses initiation, risk factors, and 

patterns of substance use and substance use 

disorders among women across the lifespan. 

2. Significant relationships and other adult 

family members may substantially infl uence 

and impact women’s behavior associated 

with treatment seeking, support for 

recovery, and relapse. 

Women may have less support from family/ 

partners than do men for seeking treatment. 

Women with alcohol problems are more likely 

to be left by their partners at the time of entry 

into treatment (Lex 1991), and their partners 

are less likely to stay with them after completion 

of treatment. Unless they themselves are 

involved in treatment or recovery, partners with 

substance use disorders may be unsupportive of 

women’s treatment seeking (Brady and Ashley 

2005). Couples in which both partners have 

substance use disorders and in those in which 

only the woman has a substance use disorder 

are more likely to spend time separated after 

treatment than are couples where only the man 

has a substance use disorder (Fals-Stewart et al. 

1999). At the same time, husbands who do not 

themselves have substance use disorders expect 

greater change from wives with substance use 

disorders in treatment than if the circumstances 

were reversed (Fals-Stewart et al. 1999). 

At times, substance use and the rituals 

associated with use may be a signifi cant 

ingredient and symbol of intimacy and closeness 

in relationships. This history and relational 

pattern may make recovery more challenging 

during and after treatment. Especially in the 

early phase of recovery, women may believe that 

their decision to not use is or will be perceived 

as a direct threat against their signifi cant 

relationship or family. Hence, women are more 

likely to relapse due to interpersonal problems 

and conflicts, and relapse is more likely to occur 

in the presence of a significant other (McKay et 

al. 1996; Rubin et al. 1996; Sun 2007). To obtain 

more information on relational factors that 

influence women across the continuum from risk 

factors to relapse, see chapters 2, 5, 6, 7, and 8. 

3. For women, pregnancy, parenting, and 

childcare influence alcohol and drug 

consumption and increase the likelihood of 

entering and completing substance abuse 

treatment. 

For many women, including those with 

substance use disorders, use of alcohol, tobacco, 

and/or illicit drugs significantly decreases after 

becoming aware of their pregnancy (Tough et 

al. 2006). It is also not uncommon for women 

who abstained from alcohol, drugs, and 

tobacco during pregnancy to return to use after 

childbirth. So, the impact of pregnancy on 

patterns of consumption can present a doubleedged sword in treatment planning. On the one 

hand, pregnancy may represent a “teachable 

moment” where motivation to protect the fetus 

can be expanded to help motivate the mother to 

make more permanent changes in her substance 

use behavior. On the other hand, progress 

toward recovery made by pregnant women 

may be transient if this progress is primarily in 

response to the pregnancy itself. 

Women are much more likely than men to 

enter treatment because it affects child custody 

(Grella and Joshi 1999). If they are able to have 

their children in treatment, women are more 

likely to enter treatment, participate and stay in 

the program, and maintain abstinence (Brady 

and Ashley 2005; Lungren et al. 2003; Szuster 

et al. 1996). Likewise, women with children 

in treatment have better treatment outcomes 

in major life areas in comparison to women 

who are without their children in treatment 

(Stevens and Patton 1998). Women in recovery 

see the support of their children as an essential 

ingredient for their recovery (Tracy and 

10 Creating the Context 
Martin 2007). Every chapter of this TIP covers 

issues pertaining to pregnancy, parenting, or 

child care, with specific attention to treatment 

modalities and treatment issues highlighted in 

chapters 5 and 7. 

4. Women are more likely to encounter 

obstacles across the continuum of care 

as a result of caregiver roles, gender 

expectations, and socioeconomic 

hardships. 

• 	Women with substance use disorders 

have enhanced treatment needs related 

to pregnancy, care of children, and other 

caregiver roles. Familiarity with these 

gender-based experiences can contribute 

to effective treatment programming and 

successful treatment outcomes. To begin 

with, pregnancy itself can be an obstacle 

to treatment because substance abuse 

treatment programs are not always able 

to admit pregnant women or to provide 

the services required. Beyond pregnancy, 

women often assume many other caregiver 

roles, and these roles can signifi cantly 

interfere with treatment engagement and 

regular attendance at treatment services. 

Brady and Ashley (2005) reported that 

women are more likely to encounter 

difficulties surrounding treatment 

attendance due to family responsibilities. 

Often family expectations regarding 

responsibilities involve care for other 

family members and the need to attend to 

their signifi cant relationship. 

• 	Most women with substance use disorders 

have to contend with economic and 

social factors as well as individual and 

family issues to negotiate their recoveries 

successfully. Because women frequently 

earn less than men for doing the same 

job, they face more economic barriers 

to entering and staying in treatment 

than do men. Women are less likely 

than men to be able to pay out-ofpocket for treatment, have less access 

to private health insurance, are less 

likely to have savings or other fi nancial 

resources to support themselves while 

in treatment, and often cannot afford a 

car to take them to treatment. According 

to NSDUH (SAMHSA 2003), 34 percent 

of women who reported they did receive 

substance use treatment indicated that 

they could not cover treatment costs 

due to inadequate or nonexistent health 

insurance. As important, women with 

co-occurring serious mental illness and 

substance use disorders were less likely to 

be employed full-time than women with 

only a substance use disorder (SAMHSA 

2003). Many female clients need assistance 

with transportation; affordable, safe 

housing; and onsite child care and other 

services for their children. To obtain more 

specific information on obstacles pertinent 

to women in treatment, refer to chapter 5. 

5. Despite the unique challenges, women 

are more likely to engage in help-seeking 

behavior and in attending treatment after 

admission. 

Women are more likely to seek health and 

mental health services than are men. Studies 

have found that women with alcohol use 

disorders as well as drug use disorders marked 

with severity are either as likely as or more 

prone to initiate treatment than men (Moos et 

al. 2006; Weisner et al. 2001). Once women are 

admitted to substance abuse treatment, they 

are at least as likely as men to participate and 

stay in treatment. Help-seeking behavior among 

women with substance use disorders appears 

to remain consistent across time. In one study, 

Chatham et al. (1999) found that women, in 

comparison to men, were more likely to seek 

further help for both psychological issues and 

drug use 1 year postdischarge from a methadone 

maintenance program. Another study found that 

women were also more apt to seek help after a 

relapse (McKay et al. 1996). Refer to chapter 5 

of this TIP for treatment engagement strategies 

that help reinforce help-seeking behavior. 

Creating the Context 11 
6. Women report more interpersonal stressful 

life events. 

Overall, women report more interpersonal 

related stress in relation to negative affect 

whereas men report more legal and workrelated stressful life events (Kendler et al. 

2001). This difference is likely a refl ection of 

gender role expectations and socialization, and 

is evident among men and women in substance 

abuse treatment. Specifically, women entering 

treatment report a greater level of family and 

social problems as measured by the Addiction 

Severity Index (Green et al. 2002; Weiss et al. 

1997). During the week prior to relapse and 

on the initial day of relapse, women report 

interpersonal problems and negative affect as 

key stressors (McKay et al. 1996). For more 

information regarding interpersonal risk factors 

of use, relational treatment needs, and relapse 

risk factors associated with interpersonal stress 

among women, refer to chapters 2, 7, and 8, 

respectively. 

7. Women often take different paths in 

accessing treatment for substance use 

disorders. 

Women are more likely than men to seek 

out physical and mental health treatment, 

including substance abuse treatment. They 

are also more likely to make use of a variety of 

healthcare options including primary care and 

psychological counseling (Cherry and Woodwell 

2002). Among women with substance use 

disorders, the most frequent source of referral 

to treatment was made by self-referral followed 

by the criminal justice system and other 

community referrals, including child protective 

services (Brady and Ashley 2005). Refer to 

chapter 2 of this TIP to review more information 

regarding treatment admission characteristics 

among women. 

8. Women have unique client–counselor 

expectations and relational needs related to 

treatment. 

Women’s sociocultural role as caregivers 

predisposes them to define themselves in 

terms of social relationships and obligations. 

Through this lens, women are more likely 

to view relationship building as an essential 

treatment ingredient. If attention is given to 

establishing and maintaining relationships 

across the continuum of care, women are more 

likely to initiate, engage, and successfully 

complete treatment. Women have identifi ed 

several counselor characteristics that they 

believe contribute to treatment success—a 

projection of acceptance and care, trust and 

warmth, a non-authoritarian attitude, and a 

sense of confidence in their abilities (Fiorentine 

and Anglin 1997; Sun 2006). Likewise, women 

are more likely to stay in treatment longer if 

they receive more intensive and individual care, 

are able to maintain their parenting role while 

in treatment, and either stay within the same 

treatment services or maintain a connection with 

treatment providers throughout the continuum 

of services, including continuing care. In this 

TIP, chapter 7 covers the main factors that 

influence retention; particular attention is given 

to women’s treatment expectations surrounding 

environment, theoretical approach, therapeutic 

alliance, and counselor characteristics. 

9. Women are uniquely stigmatized in 

relationship to substance abuse. 

• 	 Stigma is a significant barrier to treatment 

and recovery. Ascribed roles and gender 

expectations across cultures affect societal 

attitudes toward women with substance 

abuse. The societal stigma toward women 

who abuse substances tends to be greater 

than that toward men, which can prevent 

women from seeking or admitting they need 

help. According to NSDUH (SAMHSA 2003), 

women who reported not receiving or not 

perceiving a need for treatment attributed 

social stigma as the primary reason. 

Women who use alcohol and illicit drugs often 

have great feelings of shame and guilt, have 

low levels of self-esteem and self-effi cacy, and 

often are devalued by other women and men. 

These feelings make it difficult for women to 

seek help or feel that they deserve to be helped. 

Additionally, women may carry internalized 

feelings of guilt and shame concerning their 

failure in maternal roles (Ehrmin 2001). Some 

women fear negative consequences, including 

12 Creating the Context 
mandatory involvement with child protective 

services, loss of child custody, or other 

legal consequences, if their substance abuse 

becomes known. Gender role expectations in 

many cultures result in further stigmatization 

of substance use, and additional challenges 

face women who are of color, disabled, older, 

lesbians, and poor. For additional information 

on gender socialization and the role of stigma 

associated with substance abuse across specifi c 

populations, review chapter 6. For additional 

discussion and material on stigmatization, 

review risk factors in chapter 2 and 

sociocultural obstacles in chapter 5. 

Developmental 

1. Women have unique life-course issues and 

events. 

Over the past two decades, the substance 

abuse field has increasingly recognized the 

importance of developmental issues over the 

entire lifespan (Klitzner 1992; White 2006). 

Changes in physiology, emotional and social 

development, and cognitive capacity as well as 

changes in social roles and expectations have 

all been associated with substance abuse and 

its treatment. Many of these life course issues 

are different or more salient for women than 

for men. The following segment covers the 

main developmental milestones for women, and 

additional information is interwoven throughout 

this TIP. 

Identity and gender expectations—the 

younger years: During adolescence and young 

adulthood, young women are likely to face 

greater gender-based sociocultural expectations 

(Gilligan et al. 1990). Consistent with this notion 

is the finding that girls and young women may 

be more susceptible to substance use-related 

social influences than are boys (Dick et al. 

2007). Substance use may play an essential role 

in exploring new experiences while forming 

identity, but it is as likely that substance use 

helps provide relief when identity formation and 

the negotiation of new gender role expectations 

becomes confusing or difficult (Arnett 2005). 

Educational, employment, and career 

issues: In a recent summary of women’s 

career development, Fitzgerald and Harmon 

(2001; p. 226) concluded that “life is, in many 

ways, less gendered than it was in the 1970s”; 

however, “there are still ways in which life and 

its opportunities are partially controlled by 

gender stereotypes” and roles. Several writers 

have argued that “women’s work lives are 

more complex than men’s” (Fitzgerald et al. 

1995; p. 76). For example, the need to balance 

career endeavors—education, training, and 

employment—with caregiver responsibilities is a 

major developmental task that more often than 

not is unique to women. 

While younger women are more likely and 

able to invest in earlier career development 

than the women of 50 years ago (Arnett 2005), 

they still do not characteristically encounter 

the same career opportunities, and for many 

women, early career aspirations may be placed 

on hold or pared down until years later due 

to pregnancy and childcare responsibilities. 

Disparity in employment opportunities, income, 

healthcare insurance, and/or childcare support 

presents unique challenges for all women, but 

significantly impacts women with substance use 

disorders and women seeking substance abuse 

treatment. Overall, women with substance use 

disorders have more pronounced employment 

barriers than men with substance use disorders 

and women without substance use problems, 

including women who are recipients of the 

Temporary Assistance to Needy Families 

program (TANF; McCoy et al. 2007; Meara 

2006). 

Pregnancy, parenting, and childcare issues: 

This developmental milestone and the issues 

involving substance use disorders and treatment 

are covered in the above social section, item 3. 

Menopause: Menopause is a complex 

biopsychosocial transition for women. Rather 

than an event, menopause is a process that 

unfolds over many years as estrogen levels 

decrease. These decreases, in turn, may lead 

to a variety of physical and psychological 

symptoms, the onset of which may precede the 

Creating the Context 13 
cessation of fertility by as much as a decade 

(Stewart 2005). For some women, cessation of 

fertility occasions a re-examination of social 

roles, which may lead to depression or anxiety 

in some and a new sense of freedom in others. 

Studies evaluating the impact of hormonal 

changes on alcohol and drug metabolism 

and the consequences of substance use on 

the development of menopause are limited. 

Yet, preliminary studies refl ect potential 

effects even though research remains mixed 

and methodological issues are evident. Most 

noteworthy, substance abuse and dependence 

may exacerbate postmenopausal risks for 

coronary heart disease, osteoporosis, and breast 

cancer in this population (Register et al. 2003). 

Caring for parents and partners: Many more 

people than ever before are having to cope 

with caring for elderly parents in addition to 

the usual demands of work and family. The 

typical pattern is that sons offer fi nancial 

assistance, and daughters and daughters-in-law 

provide the time-consuming, hands-on care. 

More than 60 percent of caregivers are female 

(National Alliance for Caregiving and American 

Association of Retired Persons [AARP] 2004). 

An estimated 80 percent of informal care 

for elders is imparted on family caregivers 

(International Longevity Center 2006), and these 

caretaking responsibilities can last 10 years or 

more. 

Women may be caught between the 

responsibilities of providing care to their 

parents or parents-in-law while simultaneously 

taking care of their own dependent children. 

Time and energy spent caring for elderly parents 

often come at the expense of other family or 

occupational roles as well as self-care. Although 

unpaid family leave is now available to many 

workers, the demands of caring for an elderly 

parent force some women to make hard choices. 

They either have to reduce or stop work or have 

to find professional and institutional care. Some 

have had to switch to part-time work, pass up 

promotions, or quit their jobs altogether. This 

decision can lead to greater risk for living in 

poverty in the later years due to terminating 

or decreasing hours of employment to care for 

aging parents (Wakabayashi and Donato 2006). 

For women with substance use disorders, the 

emotional, physical, and financial stressors are 

likely to exacerbate substance use. Moreover, 

unique obstacles exist for women with substance 

use disorders—balancing the need to care 

for their parents and the need for their own 

substance abuse treatment. 

Longer life than male partners: Women are 

more likely than men to outlive their partners. 

According to the Centers for Disease Control 

and Prevention, the general life expectancy 

for women and men is 80.4 and 75.2 years, 

respectively. Data from the Census Bureau 

indicate that almost one-half of American 

women over the age of 65 are widowed (Fields 

and Casper 2001). A recent cross-sectional 

and longitudinal study of more than 70,000 

American women ages 50 –79 (Wilcox et al. 2003) 

found that widowed women were signifi cantly 

more physically impaired than married women 

on a variety of measures, including general 

health and physical functioning, obesity, 

hypertension, and pain. Widowed women were 

also significantly lower in overall mental health 

and social functioning and significantly higher in 

depressed mood. 

The later years: Various sources of data 

suggest that alcohol problems are ordinary 

events among the elderly, and estimates of the 

prevalence of heavy drinking or alcohol abuse 

range from 2 to 20 percent for this population 

(Benshoff and Harrawood 2003). There is also 

some suggestion that the baby-boom generation 

is more likely than earlier generations to have 

been exposed to drug and alcohol use and may 

drink or consume drugs at greater rates after 

age 65. The literature on the etiology of elder 

substance use disorders is limited, but spousal 

loss is one commonly cited factor (Benshoff and 

Harrawood 2003). 

14 Creating the Context 
Organization of this TIP 

Scope 

This TIP discusses treatment for women 

from diverse cultures, ethnicities, and sexual 

orientations; women living in urban and rural 

areas; women who are pregnant, parenting, 

or without children; and women of all ages, 

socioeconomic classes, and histories. Although 

alcohol and drug effects on fetuses and neonates 

are mentioned, the details and implications 

for fetuses and neonates are not discussed in 

detail. Female adolescents are not addressed in 

this TIP. Whereas some adolescents’ needs may 

parallel those of women, their developmental 

stage requires specialized treatment. 

Information on treating adolescents can be 

found in TIP 32 Treatment of Adolescents 

with Substance Use Disorders (CSAT 1999d). 

Substance abuse treatment issues specifi c to 

male clients are addressed in the planned TIP 

Substance Abuse Treatment and Men’s Issues 

(CSAT in development f). 

Whenever possible, TIPs include empirical 

findings in support of practices they 

recommend. However, the field of substance 

abuse treatment is evolving and research can lag 

behind the innovations being pioneered in the 

field. Treatment recommendations included in 

this TIP are based on both consensus panelists’ 

clinical experience and scientifi c literature. 

When the research supports a particular 

approach, citations are provided. 

Audience 

The primary audience for this TIP is substance 

abuse treatment clinicians and counselors 

who work with women. Secondary audiences 

include administrators, educators, researchers, 

policymakers for substance abuse treatment 

and related services, consumers, and other 

healthcare and social service personnel who 

work with women with substance use disorders. 

Approach: Gender Responsive 

Treatment 

This TIP draws on the systemic framework 

of Bronfenbrenner’s ecological theory and 

CSAT’s Comprehensive Substance Abuse 

Treatment Model for Women and Children (see 

Appendix B). It is based on clinical practice and 

research centered on women. It is not derived 

primarily by comparing women with men. The 

knowledge, models, and strategies presented 

are grounded in women’s experiences and their 

unique biopsychosocial and cultural needs. 

The basic elements and principles of genderresponsive treatment are presented throughout 

this TIP, with suggestions and resources on 

how to implement such a system of care. Also 

presented are approaches to treating substance 

use disorders among women; these employ model 

treatment programs, evidence-based and best 

practices, and other research on women’s issues 

along with knowledge from related fi elds. 

Guidelines for Readers 

The consensus panel recognizes the realities 

of substance abuse treatment sometimes 

precludes implementing the wide array of 

services and programs recommended in this 

volume. Nevertheless, by presenting a variety 

of techniques for addressing the specifi c 

treatment needs of women, the panel hopes to 

increase sensitivity to these needs and options 

for improving treatment. A special feature 

throughout the TIP, “Advice to the Clinician,” 

imparts the TIP’s most direct and accessible 

guidance for the counselor. Readers with basic 

backgrounds (such as addiction counselors or 

other practitioners) can study the Advice to the 

Clinician boxes for the most immediate practical 

guidance. Brief “Note(s) to the Clinician” and 

“Note(s) to the Clinician and Administrator” are 

offered to highlight specific issues in treatment 

services. The TIP also includes “Clinical 

Activity” inserts that provide counselors 

examples of practical individual or group 

activities that support specific treatment issues 

for women. 

Creating the Context 15 
Terminology 

African American: The term is used to identify 

women who live in the United States and whose 

ancestors at some point arrived from Africa. 

Although it blurs the distinction between women 

whose families came to this country from 

Caribbean nations and other countries and 

those who came directly from Africa, it is the 

term used by the U.S. Census Bureau and by 

SAMHSA and CSAT. 

Co-occurring disorders: The term “co-occurring 

disorders” refers to a diagnosis of substance use 

disorder and one or more mental disorders. 

Gender: This term is used not just as a biological 

category, but also as a social category meaning 

society or culture shapes the definition of gender 

and shapes the socialization of each woman. 

Gender affects how women live their lives, see 

their roles and their expectations of themselves 

and others, view and interpret the world, and 

handle the opportunities open to them and the 

constraints placed on them. People enact their 

gender in the world through transactions with 

others and are guided by social and cultural 

values and conceptions (West and Zimmerman 

1987). 

Gender responsive: “Being gender-responsive 

(or woman-centered) refers to the creation 

of an environment––through site selection, 

staff selection, program development, and 

program content and materials—that refl ects an 

understanding of the realities of women’s and 

girls’ lives and that addresses and responds to 

their challenges and strengths” (Covington 2007, 

p. 1). 

Hispanic/Latina: The use of the Spanish 

feminine term “Hispanic/Latina” indicates 

a woman of Hispanic heritage. The phrase 

“Hispanic/Latino” refers to men only or a group 

of men and women. The phrase “women of 

color” refers in this document to women of racial 

and cultural groups other than Caucasian, as 

well as women who consider themselves biracial 

or multiracial. 

Substance abuse: The term “substance abuse” 

refers to both substance abuse and substance 

dependence (as defined by the Diagnostic 

and Statistical Manual of Mental Disorders, 

Fourth Edition, Text Revision [DSM-IV-TR] 

[American Psychiatric Association {APA} 

2000a]) because substance abuse treatment 

professionals commonly use the term “substance 

abuse” to describe any excessive use of addictive 

substances. In this TIP, the term refers to the 

use of alcohol as well as other substances of 

abuse. Readers should attend to the context 

in which the term occurs to determine the 

possible range of meanings it covers; in most 

cases, however, the term refers to all varieties of 

substance use disorders described by DSM-IVTR. 

16 Creating the Context 
In This
 

Chapter
 

Initiation of Use 

Among Women 

Risk Factors 


Associated with 


Initiation of 


Substance Use and 


the Development 


of Substance Use 


Disorders Among 


Women
 

Patterns and 


Prevalence of 


Substance Use Among 


Women
 

Prevalence of 


Substance Abuse and 


Dependence Among 


Women
 

2 Patterns of Use: 

From Initiation to 

Treatment 

Overview 

This chapter addresses patterns of substance use, abuse, and 

dependence using a continuum beginning with initial risk factors and 

concluding with common attributes associated with women entering 

treatment for substance use disorders. Information pertaining to risk 

factors linked to initiation of use, abuse of alcohol and other drugs, 

and/or the development of substance dependence is explored. Also 

examined are the potential reasons for initiation of use, means of 

introduction, and other characteristics of drug and alcohol patterns 

of use among women. In addition, to shed light on common patterns, 

this chapter provides prevalence rates of substance use, abuse, and 

dependence, including specific populations of women and substances 

as well as psychosocial characteristics of women who enter treatment. 

While this section provides a wealth of information on the unique 

psychosocial issues and patterns of use among women to aid in 

program development, the essential value for clinicians is recognizing 

that substance use disorders do not occur in a vacuum. By gathering 

information on the specific risk factors associated with initiation of 

use, people of introduction, and other individual characteristics, 

clinicians can identify clients’ potential barriers to treatment 

engagement and retention along with high-risk relapse triggers. For 

example, women who identify that their initial use was infl uenced by 

a sexual relationship and that their present use involves a signifi cant 

relationship will be more likely threatened by the potential loss of a 

relationship if they continue in treatment and recovery. In addition, 

the client may be greatly influenced by phone calls from boyfriends, 

spouses, or significant others that lead to premature termination of 

treatment. Thus, risk factors associated with either the initiation 

or continuation of use can assist clinicians in identifying specifi c 

problem areas, in anticipating intervention strategies for these 

Patterns of Use: From Initiation to Treatment 17 
specific risks, and in developing a compatible 

treatment plan and an individually tailored 

continuing care plan. 

Initiation of Use Among 

Women 

The reasons for initiation of substance use 

and the subsequent development of substance 

use disorders involve a network of factors 

among women (Maharj et al. 2005). No 

one biopsychosocial characteristic is solely 

responsible for substance initiation, abuse, or 

dependence. For women, initiation of substance 

use typically begins after an introduction of the 

substance by a significant relationship such as 

a boyfriend, partner, or spouse. Reasons for 

initiation of substance use vary among women; 

they frequently report that stress, negative 

affect, and relationships are very infl uential in 

first use. Depending on the physiological effects 

of the substance, some women report they 

initiate use due to a desire to lose weight or to 

have more energy; e.g., methamphetamine use 

(Brecht et al. 2004). 

Women initiate substance use at an older 

age than do males. According to SAMHSA’s 

Treatment Episode Data Set (TEDS; SAMHSA 

2004), the average age of first use of drugs or 

alcohol for females is almost 20 years old. In 

reviewing gender differences in initiation of use 

between males and females, a key ingredient that 

appears paramount is the opportunity to use. 

While females currently have fewer restrictions 

than in the past, they generally encounter more 

parent-imposed restrictions and constraints 

on activities, greater parental monitoring, and 

higher expectations surrounding responsibilities 

in the home. These restrictions often limit 

drug and alcohol exposure and opportunity to 

use (van Etten and Anthony 2001). Yet, when 

women across ethnically diverse groups have the 

same opportunity as men, they are just as likely 

to initiate use. In recent years, women have had 

more opportunities and greater availability in 

accessing drugs and alcohol (van Etten et al. 

1999). 

Risk Factors Associated 

with Initiation of 

Substance Use and the 

Development of Substance 

Use Disorders Among 

Women 

Why one woman uses a substance without 

becoming dependent while another progresses 

to abuse and dependence is not entirely clear. 

Substance use disorders have complex and 

interrelated causes. For women, some factors 

are associated only with initiation of use, while 

other factors are associated with progression 

from initial use to substance dependence; e.g., 

co-occurring disorders (Agrawal et al. 2005). 

Just as some factors increase the likelihood of 

women developing substance abuse problems, 

others decrease those chances. For example, 

having a partner can be a risk factor if that 

person abuses alcohol or drugs, but having a 

supportive, caring partner who does not use 

alcohol or drugs can be a protective factor. 

In this section, risk factors associated with 

initiation of use, ongoing alcohol and drug 

involvement, and alcohol and drug abuse and 

dependence are explored. 

Familial Substance Abuse 

Substance use disorders aggregate in families: 

relatives of people with substance use disorders 

are more likely to have a disorder. In all 

likelihood, both genetic and environmental 

factors play important and interconnected 

roles. Most research on familial aggregation has 

been done on alcohol use disorders and on male 

subjects. Reviews of several studies indicate 

that parental substance abuse can infl uence 

the development of substance use disorders in 

their children (Finkelstein et al. 1997; Heath et 

al. 1997). Jennison and Johnson (2001) cite a 

growing body of research on the risk for adult 

children of parents who abuse alcohol. The 

literature indicates that women are affected by 

familial substance abuse as much as men, with 

18 Patterns of Use: From Initiation to Treatment 
a prevalence of alcohol dependence from 10 to 

50 times higher than women who do not have a 

parent who abuses substances. 

Twin and adoption studies have established 

an important role for genetic influences in the 

etiology of alcohol use disorders in men. Some 

studies show that genetic factors appear to be 

important in women as well, making women 

similarly vulnerable to substance abuse from 

a genetic standpoint (Johnson and Leff 1999; 

Merikangas and Stevens 1998; Pickens et al. 

1991). A study of 1,030 female twins found that 

alcohol use disorders were consistently higher 

in identical twins than in non-identical twins 

and suggested that women’s genetic likelihood 

of developing an alcohol use disorder is in the 

range of 50 to 60 percent (Kendler et al. 1992). 

Kendler and Prescott (1998) found that among 

women, genetic risk factors have a moderate 

effect on the probability of ever using cannabis 

and a strong effect on the likelihood of heavy 

use, abuse, and, probably, dependence. 

However, on the whole, the evidence for genetic 

influence on the development of alcohol use 

disorders in women is less consistent than 

for men. Interpretation of the literature is 

complicated by methodological issues, such as 

small sample sizes. Some research suggests that 

differences between men and women exist in the 

sets of genes that influence alcohol use disorder 

risk or perhaps in the interactions of genes 

contributing to alcohol use disorder risk with 

other genetic or cultural factors (Prescott 2002). 

A study of women who were adopted found that 

early-life family conflict and psychopathology 

in the adoptive family interacted with a 

biological background of alcohol use disorders. 

Among women with at least one biological 

parent with an alcohol use disorder, confl ict 

or psychopathology in the adoptive family 

increased the probability of alcohol abuse or 

dependence (Cutrona et al. 1994). 

A number of possible explanations could 

account for this genetic and behavioral parental 

impact (Heath et al. 1997; Johnson and Leff 

1999). Parents who use alcohol and illicit drugs 

sometimes are unable to supervise their children 

and protect them from physical or sexual 

abuse by other family members or strangers 

(Moncrieff and Farmer 1998). They more often 

are emotionally unavailable to nurture and help 

their children. According to Johnson and Leff’s 

(1999) review of the literature, alcohol use by 

parents is both directly linked to alcohol use 

by children and indirectly linked to stress, less 

parental supervision, and greater emotional 

volatility. Jessup’s (1997) review indicates that 

when parents have substance use disorders, 

it signals to a child that coping with problems 

by using alcohol and illicit drugs is acceptable 

behavior. 

Family of Origin Characteristics 

Across ethnic and cultural population groups, 

major risk factors for substance initiation and 

dependence among women include chaotic, 

argumentative, blame-oriented, and violent 

households. As a general tenet, women who 

grew up in families where they take on adult 

responsibilities as a child, including household 

duties, parenting of younger children, and 

emotional support of parents, are more likely 

to initiate drug and alcohol use. Women who 

are dependent on substances are more likely 

to have a history of over-responsibility with 

their family of origin (Nelson-Zlupko et al. 

1995). While prevalence of alcohol dependence 

appears consistently higher among women who 

report parental alcohol abuse regardless of the 

number of adverse childhood experiences (Anda 

et al. 2002), these experiences, characterized 

by childhood abuse and various forms of 

dysfunctional households, signifi cantly increase 

early initiation of use on or before the age of 14 

(Dube et al. 2006). 

Marital Status 

Women (18 to 49 years of age) who are married 

have a lower rate of alcohol or illicit drug abuse 

or dependence than women of any other marital 

status (SAMHSA 2003). History of divorce is 

positively associated with illicit drug use, not 

drug dependence, among women (Agrawal et al. 

2005). Approximately 11 percent of divorced 

Patterns of Use: From Initiation to Treatment 19 
or separated women and 16 percent of women 

who have never married (in age range of 18 to 

49 years) abuse or are dependent on alcohol 

or an illicit drug compared to only 4 percent of 

married women (SAMHSA 2004). 

Effect of Partner Substance Abuse 

The “interaction, assistance, and encouragement 

of other people” are major factors in women’s 

substance use and abuse (Finkelstein 1996, 

p. 30). One study found that to some degree 

partners influence each other’s drinking 

patterns (Wilsnack et al.1998b). Men who drink 

alcohol more frequently than their partners 

influence them to drink more often, and women 

who drink lightly influence their partners to 

drink less (Wilsnack et al. 1998b). 

Women dependent on illicit drugs are more 

likely than males dependent on illicit drugs to 

have partners who use illicit drugs (Lex 1995). 

Although alcohol and marijuana use often begins 

with peer pressure during adolescence, women 

are likely to be introduced to cocaine and 

heroin by men (Amaro and Hardy-Fanta 1995; 

Henderson et al. 1994). Some women continue 

using alcohol and illicit drugs to have an activity 

in common with their partners or to maintain 

the relationships. The man often supplies drugs, 

and the woman becomes dependent on him for 

drugs. Among women with partners who have 

alcohol-related problems, they are more likely to 

report mental health problems including mood, 

anxiety, and quality-of-life problems as well as 

substance use disorders (Dawson et al. 2007). 

The dynamic of one partner being the supplier 

and the other using the drug to maintain the 

relationship is present also in some same-sex 

relationships. A few studies have examined the 

effects of partner substance abuse in lesbian 

relationships, especially the association between 

substance use and violence, but little is actually 

known (Hughes and Norris 1995; Schilit et al. 

1990). 

Women are at risk of contracting HIV/AIDS 

and hepatitis from sharing needles or having 

sexual relations with men who inject drugs or 

have sex with men. Some women may have 

unrealistic notions about intimacy, assume their 

partners are monogamous, or fear alienating 

their partners by demanding safe sex practices. 

Women with a history of abuse may have 

particular problems negotiating the use of these 

practices. 

Although ending a bad relationship can lessen 

stress, it also causes psychological distress (Hope 

et al. 1999; Horwitz et al. 1996) and can increase 

alcohol use and related problems (Chilcoat and 

Breslau 1996; Neff and Mantz 1998; Power et 

al. 1999), especially among women (Fillmore et 

al. 1997; Horwitz et al. 1996). The situation is 

more complicated when a couple has a child and 

the woman may feel unable to leave the child’s 

father for emotional or financial reasons (Amaro 

and Hardy-Fanta 1995). 

Partners may prevent women from entering or 

staying in treatment (Tuten and Jones 2003). A 

study of male partners of women in treatment 

for crack/cocaine found that most of the men 

accepted their partners’ drug use as long as 

the women managed to care for the home and 

children (Laudet et al. 1999). This study notes 

the difficulty of involving male partners in 

women’s treatment. Despite the fact that nearly 

two-thirds of the men said they supported their 

partners in treatment, they found this support 

to be passive and inconsistent. Laudet and 

colleagues (1999) suggest a number of possible 

reasons for the male partners’ detachment: 

the males’ own alcohol and drug use, desire to 

maintain the status quo, different treatment 

goals, preoccupation with their own treatment, 

and fear of stigma. 

Personality Measures 

Novelty-seeking was positively associated more 

with initiation of illicit drug use than with 

Protective Factor—Parental Warmth: If a woman comes from a family of origin that has high 

parental warmth, she is less likely to initiate use, abuse substances, or become dependent on 

alcohol or other substances (Agrawal et al. 2005) 

20 Patterns of Use: From Initiation to Treatment 
Protective Factor—Partner Support: In their study of nearly 4,500 women, Jennison and 

Johnson (2001) found that a good marriage was protective against the development of alcohol 

abuse in women with a familial history of alcohol abuse. Partners can be the key motivators in 

successful interventions that bring a woman to treatment. Treatment readiness and willingness to 

accept help are higher in women whose partners have been in treatment (Riehman et al. 2000). 

progression from use to abuse/dependence 

(Agrawal et al. 2005). Among women, sensationseeking (risk-taking personality) has signifi cant 

effects on substance use. One study (VanZileTamsen et al. 2006) that examined the impact of

personality constructs on health risk behavior 

among women showed that sensation-seeking ha

large indirect effects on risky sexual behavior, 

affiliation with risky partners, and drinking an

illicit drug use behavior, and that sensationseeking is more strongly associated with 

substance use than with sexual risk behavior. 

Premorbid personality risk factors that lay 

the foundation for substance abuse (besides 

depressive features) include obsessiveness 

and anxiety, difficulty in regulating affect 

and behavior (such as temper tantrums and 

frequent tearfulness), and low self-worth and 

ego integration (Brook et al. 1998). According 

to Page (1993), a negative self-perception 

of physical attractiveness is associated with 

s 

d 

increased illicit drug use. 

Sexual Orientation 

Studies show higher rates of substance use 

and dependence in women who have sex with 

women compared with heterosexual women 

(Bickelhaupt 1995; Cochran et al. 2000; 

Diamant et al. 2000; UCLA Center for Health 

Policy Research 2005). Hughes and Wilsnack 

(1997) conclude that lesbians differ from 

heterosexual women in that they are less likely 

to abstain from alcohol, have higher rates of 

alcohol problems, and do not decrease alcohol 

intake as much with age. Conversely, Drabble 

and Underhill (2002) note that two studies found 

no significant differences in levels of drinking 

between lesbians and heterosexual women and 

that lesbians who did not drink were more likely 

to report being in recovery. Heffernan (1998) 

suggests these comparable rates of drinking 

among lesbian and heterosexual women are 

perhaps the result of a greater emphasis on 

sobriety in the lesbian community over the past 

decade. 

Studies have reported greater prevalence of 

marijuana use in comparison to other illicit 

drugs among lesbians (Cochran et al. 2004). In a 

study reporting elevated rates of illicit drug use 

among lesbian and bisexual women, marijuana 

was the most prevalent (33 percent), followed 

by opioids other than heroin (15.1 percent), 

and tranquilizers (11.6 percent; Corliss et al. 

2006). Lesbians who have moderate or highrisk levels of use, measured by patterns of 

drug use and severity, were also more likely to 

report depressive symptoms, and this pattern 

of depressive symptoms is reflected in Hispanic/ 

Latina and Asian populations (Cochran et al. 

2007). Among younger lesbians and bisexual 

women, they appear to be most likely to abuse 

prescription drugs (Kelly and Parson 2007). 

Empirical studies reveal that lesbians are 

more likely to smoke than heterosexual women 

(Hughes and Jacobson 2003). 

Protective Factor—Religious and Spiritual Practices: Numerous studies (for review, see 

Matthews et al. 1998) highlight that higher levels of personal devotion, religious affi liation, and 

religious beliefs (defined as religiosity) reduce the risk for substance use and dependence. A female 

twin study found a negative association between religious beliefs and illicit drug use (Agrawal et al. 

2005)—that religiosity is associated with a reduced risk for substance abuse. Consistent with other 

studies (Kendler et al. 1997; Kendler et al. 2003), this study suggests that religiosity is a protective 

factor in substance use and abuse, and that faith-based approaches may serve as a potential 

relapse prevention strategy. 

Patterns of Use: From Initiation to Treatment 21 
Lesbians who have a history of child sexual 

abuse possess a heightened risk for lifetime 

alcohol abuse in comparison to lesbians 

without a similar abuse history (Hughes et al. 

2007). Adolescent females and women who 

are either struggling with issues or prejudice 

surrounding sexual orientation also have greater 

risks in initiating and maintaining drug and 

alcohol use (McKirnan and Peterson 1992). 

More information on treating lesbian clients 

is available in A Provider’s Introduction to 

Substance Abuse Treatment for Lesbian, Gay, 

Bisexual, and Transgender Individuals (CSAT 

2001b). 

History of Interpersonal Violence, 

Childhood Sexual Abuse, and 

Other Traumas 

A history of traumatic events including, but 

not limited to, sexual and physical assaults, 

childhood sexual and physical abuse, and 

domestic violence, are signifi cantly associated 

with initiation of substance use and the 

development of substance use disorders among 

women (Agrawal et al. 2005; Brady and Ashley 

2005; Hawke et al. 2000; Pettinati et al. 2000). 

One review found a lifetime history of trauma 

in 55 to 99 percent of women who abused 

substances, compared with rates of 36 to 51 

percent in the general population (Najavits et 

al. 1997). Although not every woman who has 

a history of trauma develops posttraumatic 

stress disorder (PTSD), it is important to note 

that traumatic experiences are associated with 

substance use and subsequent substance use 

disorders. Several interpretations have been 

offered to explain why substance abuse often 

accompanies trauma. Studies (Grayson and 

Noelen-Hoeksema 2005; Jarvis et al.1998; 

Schuck and Wisdom 2001; Testa et al. 2003; 

Ullman et al. 2005) suggest that some survivors 

of sexual and/or physical abuse may use 

substances to self-medicate their depression 

or the anxiety that results from the abuse. 

Some survivors who use primarily cocaine and 

amphetamines may be trying to increase their 

vigilance against further victimization. Others 

with low self-esteem may use alcohol to increase 

their sociability. Conversely, substance use 

disorders increase a woman’s vulnerability 

to additional trauma, decrease her ability to 

Note to Clinicians 

For those women who are more likely to seek out novel events and thrive on risk-taking behavior 

or those women who are accustomed to living in high stress or in crisis, one of the challenges in 

maintaining recovery is learning to engage in day-to-day activities without seeking out or creating 

these situations. Some women may be so used to higher levels of stress that when life becomes a 

little more settled without the use of alcohol and drugs, they may experience a sense of boredom, 

uncomfortable feelings, or a sense of being down or depressed. In recovery, women may place 

themselves in circumstances that are high risk for relapse by returning to old risk-taking 

behaviors or by creating stressful situations to offset these feelings. 

As a clinician, it is important to anticipate these behaviors and reactions and to begin teaching 

strategies to manage these experiences. Using anxiety management strategies can be invaluable, 

but it is important to teach these techniques as early as possible to help build an arsenal of coping 

skills. Women need to learn about their accustomed risk-taking levels and premorbid levels 

of stress and the subsequent consequences if they engage in sensation-seeking behaviors. By 

developing alternative, healthy behaviors, some women will discover they don’t need to maintain 

the same level of stress to function as in the past, while other women will learn they can exchange 

their destructive desire for excitement with other recovery-oriented activities; e.g., enrolling in 

an exercise class (with medical clearance) or telling their recovery story at a 12-Step speakers 

meeting. 

22 Patterns of Use: From Initiation to Treatment 
defend herself, alter her judgment, and draw 

her into unsafe environments. 

Kilpatrick and colleagues (1997) speak of 

the “vicious cycle” of substance abuse and 

violence, in which violence is both a risk factor 

and a consequence of substance abuse. TIP 

25, Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b), defi nes domestic 

violence as “the use of intentional emotional, 

psychological, sexual, or physical force by one 

family member or intimate partner to control 

another” and provides an array of means 

of abuse: “verbal, emotional, and physical 

intimidation; destruction of the victim’s 

possessions; maiming or killing pets; threats; 

forced sex; and slapping, punching, kicking, 

choking, burning, stabbing, shooting, and killing 

victims” (p. 1). 

The actual introduction to substances by a 

significant other can be a way of increasing 

control and establishing power over some 

women. While rates of domestic violence vary 

across studies, it is evident that there is a 

significant relationship between violence and 

substance initiation, abuse, and dependence. 

In one survey study assessing the prevalence of 

domestic violence among women in substance 

abuse treatment, 60 percent of women reported 

either current or past domestic violence, 47 

percent reported current domestic violence 

at treatment intake, and 39 percent reported 

either physical or emotional abuse in the past 

year leading up to treatment (Swan et al. 2000). 

Moreover, the prevalence of interpersonal 

violence and substance use extends to pregnant 

women who are drug dependent. In another 

study on prevalence of violence and pregnant 

women, 73 percent reported a lifetime history 

of physical abuse. Approximately 33 percent of 

women in substance abuse treatment who were 

pregnant reported having physical fi ghts with 

their current partner in the past year (Velez et 

al. 2006). In the first analysis of evaluating the 

role of substance use as a means of coping among 

women who have experienced domestic violence 

(Kaysen et al. 2007), the results support the selfmedication hypothesis in that women use alcohol 

as a means of managing painful affect. 

Co-Occurring Substance Use and 

Mental Disorders 

Women are more likely than men to have cooccurring mental and substance use disorders 

(see chapter 8 and TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders [CSAT 2005e]). According to the 

National Comorbidity Study of women diagnosed 

with alcohol abuse, 72.4 percent have lifetime 

co-occurring mental disorders and 86 percent of 

women diagnosed with alcohol dependence have 

co-occurring disorders (Kessler et al. 1997). 

In comparison to men, women are more likely 

to have multiple comorbidity (three or more 

psychiatric diagnoses in addition to substance 

use disorder; Zilberman et al. 2003). Various 

literature on co-occurring disorders highlights 

the role of substance abuse as a means of selfmedicating distressing affect. While differences 

are noted in prevalence rates of co-occurring 

disorders among women of specifi c ethnic 

populations, Corcoran and Corcoran (2001) 

assert, based on their retrospective study, that 

gender (specifically female), appears to play a 

more salient role than ethnicity in endorsing the 

use of substances to manage negative affect. 

For women, anxiety disorders and major 

depression are positively associated with 

substance use, abuse, and dependence and 

are the most common co-occurring diagnoses 

(Agrawal et al. 2005). Other common mental 

disorders in women with substance use disorders 

are eating disorders and PTSD, a common 

sequel to violence and trauma. In a study 

screening women veterans for substance abuse 

and psychiatric disorders, 57 percent of the 

women who screened positive for depression, 

Protective Factor—Coping Skills: Engaging in problemsolving skills, mobilizing support from 

others, and learning to cope with one’s feelings are key protective ingredients (Mrazek and 

Haggerty 1994). 

. 

Patterns of Use: From Initiation to Treatment 23 
eating and panic disorders, and PTSD also 

screened positive for substance abuse (including 

tobacco use). This sample demonstrated that 

women with a positive screen for psychiatric 

conditions were twice as likely to have abused 

drugs in the last year (Davis et al. 2003). While 

it is likely that mental disorders can play a 

primary role in initiating substance use to 

gain relief, it is as important to acknowledge 

that psychiatric disorders may occur as a 

consequence of substance use or develop 

independently, yet concurrently, of the current 

pattern of substance use. 

Preliminary investigations and discussions 

suggest that some co-occurring mental disorders 

may be likely risk factors for the initiation of 

substance use and the subsequent development 

of substance use disorders (such as anxiety 

disorders and major depression), while other cooccurring disorders may be more likely to occur 

after the development of substance use disorders 

(Conway and Montoya 2007). For many women, 

the onset of the mental illness may precede 

the substance abuse, particularly in cases of 

PTSD (Brady and Randall 1999). One study 

reveals that women with PTSD were fi ve times 

more likely than women without PTSD to have 

substance use disorders (Brady et al. 2000). A 

review of several studies reveals that current 

PTSD rates among women who abuse substances 

range between 14 and 60 percent (Brady 2001; 

Najavits et al. 1998; Triffleman 2003), and that 

women who use substances are still more than 

twice as likely to have PTSD than men (Najavits 

et al. 1997). The planned TIP, Substance Abuse 

and Trauma (CSAT in development h), provides 

more information on this topic. 

Regarding eating disorders (anorexia nervosa 

and bulimia nervosa), women who are diagnosed 

with these disorders are more likely to develop 

alcohol use disorders later on (Franko et al. 

2005). Specifically, the behavioral pattern 

of purging, but not bingeing, appears to be 

associated more strongly with substance use. 

This finding is consistent with a theory that 

overeating or bingeing competes with substance 

use for the reward sites in the brain (Kalarchian 

et al. 2007; Kleiner et al. 2004; Warren et al. 

2005), and that obesity may be a protective 

factor against developing substance use 

disorders. 

Discrimination 

Discriminatory acts range from mundane 

slights to devastating violent acts. Women may 

experience varied levels of discrimination— 

based on gender, race, ethnicity, language, 

culture, socioeconomic status, sexual 

orientation, age, and disability—that affect 

their substance use and may affect their 

recovery (see chapter 6). For some women, 

substance abuse may become a way of coping 

with the additional stresses of discrimination. 

When women experience more than one 

type of discrimination, the effect can be 

compounded (Krieger 1999). Discrimination 

can result in fewer educational and employment 

opportunities, lower socioeconomic status, 

fewer choices in housing, and poorer health 

outcome (Mays et al. 2007). Less access to health 

care and difficulty in funding treatment due to 

a lack of health insurance can result in later 

referral for substance abuse treatment. These 

circumstances can lead directly and indirectly to 

negative health consequences and psychological 

distress, requiring special considerations during 

treatment (Krieger 1999). 

Acculturation 

Studies have found that as immigrants become 

increasingly acculturated into American 

society, and even as African Americans move 

closer to mainstream European/Caucasian 

lifestyles, alcohol and drug use increases. 

Acculturation can involve intergenerational 

conflict and feelings of disconnection, a struggle 

for cultural identity, and feelings of grief 

and loss related to the life left behind—all of 

which can put a woman at risk for substance 

abuse. For example, foreign-born Mexican 

Americans and foreign-born non-Hispanic 

Caucasians are at significantly lower risk 

for substance use disorders than are their 

American-born counterparts (Grant et al. 

2004). Second- and third-generation Hispanics/ 

Latinas are more likely than their mothers to 

use alcohol and illicit drugs (Mora 2002). A 

24 Patterns of Use: From Initiation to Treatment 
Clinical Activity: Sample Timeline 

Clinical Activity: Timeline Exercise 

When working with individuals with co-occurring disorders, it is often a challenge to understand 

the history and development of symptoms and the chronological relationship between each 

disorder. While it would be valuable to understand the temporal relationship between disorders 

and to determine which set of symptoms and disorder came fi rst, it is generally information 

that is diffi cult to obtain. Nonetheless, clinicians can help clients gain awareness of the 

interrelationship between disorders and symptoms and how one disorder may exacerbate the 

other or serve as a coping mechanism to manage symptoms. To lay the groundwork to help clients 

understand this relationship, a simple timeline exercise can be implemented to highlight the 

prevalence and presenting symptoms across time. 

Directions: On a piece of paper, draw a straight line from birth to current age. Mark the line 

either in 1-year or 5-year increments depending on the age of the client and the duration of the 

disorders. Start with one disorder and mark the approximate onset of the initial symptoms, 

then write in the symptoms starting with the initial occurrence (approximate) and add the 

subsequent symptoms across the timeline. Once you have completed one disorder, go back (use a 

different color pen or marker) and do the same for the next. Use the timeline as a tool to promote 

discussion. Don’t forget to process feelings that may surface during this exercise. Note: As a 

clinician, it can be enticing to add other variables from the start, but usually it is better to start 

out simple and then return to the timeline in the next individual or group session to explore other 

issues, such as rating severity of use on the timeline 

A sample timeline is provided below. This timeline was developed for a patient with a history of 

an eating disorder (anorexia nervosa) and alcohol dependence. Not all symptoms have been noted 

on this timeline for either disorder. 

Patterns of Use: From Initiation to Treatment 25 
suggested explanation for this increase in use 

among younger Latinas is confl icting cultural 

expectations; their mothers and grandmothers 

are more constrained by traditional cultures. 

Socioeconomic Status 

Women with substance use disorders are more 

likely to have lower incomes and less education 

and are less likely to be employed. Employment 

status appears to be a factor associated with 

alcohol and drug abuse and dependence. Drug 

abuse and dependence are higher among women 

who are unemployed; in 2003, 12.5 percent of 

women aged 18 to 49 who were unemployed 

abused or were dependent on alcohol or an illicit 

drug compared with 8 percent of women who 

were employed full time (SAMHSA 2004). The 

temporal relationship between unemployment 

and the development of substance use disorders 

is rather complex and not well understood. 

Patterns and Prevalence 

of Substance Use Among 

Women 

This section covers specific prevalence rates 

associated with women’s initiation of substance 

use. Similar to males, females initiate use 

based on, but not limited to, alcohol and 

drug availability, level of ease in obtaining 

the substances, price of substances, the ratio 

between perceived drug benefit versus perceived 

risk associated with use, and general attitude 

toward substance use. Yet, women typically 

display different patterns of use with alcohol, 

illicit and prescription drugs, and tobacco. 

The following segment highlights these unique 

patterns. 

Prevalence of Substance Use: 

Alcohol, Illicit Drugs, Prescription 

Drugs, and Tobacco 

Alcohol and illicit drugs 

SAMHSA’s National Survey on Drug Use 

and Health (NSDUH) interviews yearly more 

than 67,000 persons ages 12 or older to assess 

their use of alcohol and illicit drugs and their 

symptoms of substance abuse or dependence 

during the past year (SAMHSA 2007). Results 

of NSDUH for 2006 indicate that 45.2 percent 

of females ages 12 or older used alcohol during 

2006, and 6.2 percent reported current illicit 

drug use. Figure 2-1 (p. 29) provides more 

specific information about the use of illicit 

drugs, alcohol, and tobacco by females ages 12 

and older. 

Prescription drugs 

An analysis of data from the National Medical 

Expenditures Survey shows women not only use 

significantly more prescription drugs than men, 

they also use significantly more prescription 

drugs with addictive properties. Compared with 

men, women are 48 percent more likely to use a 

prescription drug that can be abused (SimoniWastila 2000). According to the NSDUH 2004 

survey, between 2003 and 2004, the number 

of persons aged 12 or older with lifetime 

nonmedical use of pain relievers increased from 

31.2 million to 31.7 million including the use of 

Vicodin, Lortab, Lorcet, Percocet, Percodan, 

Tylox, hydrocodone products, OxyContin, 

and oxycodone products (SAMHSA 2005). The 

NSDUH 2003 survey found that 55 percent of 

new people who used these prescription drugs 

were female (SAMHSA 2004). 

Tobacco 

The importance of tobacco use should not be 

underestimated in a discussion of substance 

abuse. The negative physical consequences are 

well documented and can be fatal—increased 

risk for cardiovascular disease and stroke; 

chronic obstructive pulmonary disease; and 

lung, bladder, and other cancers—and specifi c 

risks are related to gender (see chapter 3). 

Tobacco use among American women has 

decreased from a high of 34 percent in 1965 to 

23.3 percent in 2006 (SAMHSA 2007). Among 

females ages 12 or older, 22.2 percent smoked 

cigarettes in the past month during 2006. Less 

than 1 percent of women reported current 

use of a smokeless tobacco product, and 2.1 

percent reported smoking cigars. Women who 

use smokeless tobacco (ST) reported using ST to 

manage weight and in response to mood states. 

26 Patterns of Use: From Initiation to Treatment 
Six Patterns Associated with Women’s Substance Use 

1. Narrowing of the Gender Gap: In comparing male and female rates of alcohol use across 

10 years (Grant et al. 2006), there is significant evidence of the gender gap narrowing. Overall, 

younger adult females are more likely to mirror male patterns of alcohol and illicit drug use 

than older females. This shrinking gender gap for alcohol and drug use has been noted across 

ethnic groups, especially among younger women. 

2. People of Introduction and Relationship Status: Women are more likely to be introduced 

to and initiate alcohol and drug use through significant relationships including boyfriends, 

spouses, partners, and relatives. According to the National Center on Addiction and Substance 

Abuse and Columbia University (CASA) research report, females are often introduced to 

substances in a more private setting (2003). In addition, marital status plays an important role 

as a protective factor in the development of substance use disorders. 

3. Drug Injection and Relationships: Even though women are less likely to inject drugs than 

men, research suggests that women accelerate to injecting at a faster rate than men (Bryant 

and Treloar 2007). When women inject drugs for the first time, they are more likely than men 

who are first-time injectors to be introduced to this form of administration by a sexual partner 

(Frajzyngier et al. 2007). Women are more likely to be involved with a sexual partner who also 

injects. While various personality and interpersonal factors influence needle sharing among 

women (Brook et al. 2000), women are more likely to inject with and borrow needles and 

equipment from their partner, spouse, or boyfriend. Among women who use with their sexual 

partners, Bryant and Treloar (2007) highlight a division of labor where men are responsible for 

obtaining, purchasing, and injecting the drug for them. Thus, needle sharing and drug using 

with a sexual partner may engender a sense of emotional intimacy among women or refl ect 

inequity of power in the relationship. Other “people of introduction” besides sexual partners 

are groups that are predominantly female. While women may initiate drug injection through 

relational means, it is important to recognize that some women are as likely to initiate drug 

injection on their own. 

4. Earlier Patterns Reflect Later Problems: Drinking low to moderate levels of alcohol 

in early adulthood is a predictor of later heavy drinking and alcohol-related substance use 

disorders among women (Andersen et al. 2003; Morgen et al. 2008). In addition to amount of 

alcohol intake, frequency of use appears positively associated with risk of alcohol dependence, 

particularly for women (Flensborg-Madsen et al. 2007). Females who begin smoking at a young 

age are more likely to initiate alcohol and drug use than females who do not smoke. 

5. Responsibilities and Pattern of Use: Women are more likely to temporarily alter their 

pattern of use in response to caregiver responsibilities. As an example, women are likely to 

curtail or establish abstinence of alcohol and illicit drugs while pregnant (SAMHSA 2004), even 

though they are as likely to resume use later on. In addition, some women report that they use 

stimulants to help meet expectations associated with family responsibilities (Joe 1995). 

6. Progression and Consequences of Use: Women experience an effect called telescoping 

(Piazza et al. 1989), whereby they progress faster than men from initial use to alcohol and 

drug-related consequences even when using a similar or lesser amount of substances. While 

extensive research is available pertaining to the telescoping effect of alcohol and alcohol-related 

consequences among women, more recent research (Hernandex-Avila et al. 2004; Ridenour et 

al. 2005) supports a preliminary finding—a similar pattern of rapid progression for illicit drugs. 

While women have a greater biological vulnerability to the adverse consequences of substance 

use, it is important to note that variations in progression and the biopsychosocial consequences 

of substance use may also be linked to socioeconomic status, racial/ethnic differences, and age 

(Johnson et al. 2005). As an example, African Americans generally begin regular alcohol use 

later than most population groups yet demonstrate more rapid transition from initiation of use 

to abuse. 

Patterns of Use: From Initiation to Treatment 27 
In addition, women reported that initiation of 

use was signifi cantly influenced by other females 

who use (Cohen-Smith and Severson 1999). 

Data from the 1997–1998 National Center for 

Health Statistics’ National Health Interview 

Survey revealed that among racial or ethnic 

groups, American-Indian and Alaska-Native 

women have the highest prevalence of tobacco 

use with 34.5 percent; Asian- or Pacifi cAmerican women have the lowest prevalence 

at 11.2 percent (Office of the Surgeon General 

2001b). Women with more education tend to 

smoke less than women with less education. 

According to the survey, the lowest rates among 

people who smoke were for women with more 

than 16 years of education, and the highest rates 

were for women with 9 to 11 years of education. 

There is increasing evidence that children of 

parents who smoke cigarettes are more likely to 

smoke than the children of parents who do not 

smoke. Although some studies show confl icting 

results, girls seem to be more influenced by their 

parents’ smoking and are particularly more 

likely to model maternal behavior. This applies 

not just to smoking but also to cessation. The 

Office of the Surgeon General (2001b) reports 

one study that found when mothers stopped 

smoking, it helped delay or deter smoking in 

adolescent daughters, but not in sons. 

Although there is debate about the relevance 

of the “gateway” concept (in which use of 

one substance leads to use of other more 

“dangerous” substances), many studies show 

that tobacco use precedes alcohol and drug 

use. Young women in particular who smoke 

tobacco are more likely than young women who 

do not smoke to drink alcohol or use drugs, 

especially when they begin smoking at a young 

age (Ellickson et al. 1992; Lai et al. 2000; Torabi 

et al. 1993). Based on these studies, associated 

behaviors and environmental factors play a 

probable role in initiating tobacco, alcohol, and 

drug use. 

Prevalence of Substance Use 

Patterns Among Women Who Are 

Pregnant 

NSDUH includes questions about the use of 

alcohol, illicit drugs, tobacco, and pregnancy 

status among women ages 15 to 44; results show 

past-month rates for substance use are curtailed 

substantially during pregnancy (see Figure 2-2 

on p. 30; SAMHSA 2008). These rates are likely 

to be conservative because they reflect only pastmonth use, not use during the entire pregnancy. 

They also are limited to women who were aware 

of their pregnancies at the time of the survey. 

Responses are affected by an unknown degree of 

stigma associated with using substances during 

pregnancy. 

Among pregnant women ages 15 to 44 years, 

5 percent reported using illicit drugs in the 

past month, based on combined 2006 and 2007 

NSDUH data. This rate is signifi cantly lower 

than the rate among women ages 15 to 44 who 

were not pregnant (10.0 percent). The rate of 

past-month cigarette use was also lower among 

those who were pregnant (16.4 percent) than it 

was among those who were not pregnant (28.4 

percent). Alcohol use followed a similar pattern 

among pregnant women ages 15 to 44 with an 

estimated 11.6 percent reporting past-month 

alcohol use. This rate was signifi cantly lower 

than the rate for nonpregnant women in the 

same age group (53.2 percent). 

These data are encouraging, indicating that 

women tend to reduce their substance use 

during pregnancy. However, women’s reduction 

of substance use during pregnancy appears to 

be temporary (SAMHSA 2008). NSDUH data 

suggest that women ages 15 to 44 use alcohol, 

tobacco, and illicit drugs less during pregnancy 

but are likely to resume substance use after 

pregnancy. 

Women who continued to use illicit drugs 

occasionally or regularly after their last 

menstrual period are more likely to have a 

28 Patterns of Use: From Initiation to Treatment 
Figure 2-1 

Use of Illicit Drugs, Alcohol, and Tobacco by Females Aged 12 or 

Older, Past Year and Past Month, Numbers in Thousands and 

Percentages, 2006 

Past Past Past Year Past Year Month Month Number Percent Number Percent 

Any Illicit Drug 15,007 11.8 7,816 6.2 

Marijuana (includes hashish) 9,785 7.7 5,162 4.1 

Any Illicit Drug Other Than Marijuana 9,310 7.4 4,019 3.2

 Cocaine 2,116 1.7 797 0.6

 Crack 453 0.4 182 0.1

 Heroin 184 0.1 77 0.1 

Hallucinogens (LSD, PCP, Ecstasy) 1,593 1.3 428 0.3

 Inhalants 875 0.7 257 0.2 

Nonmedical Use of Any 

Psychotherapeutics 7,509 5.9 3,141 2.5

 Pain Relievers 5,427 4.3 2,206 1.7

 Tranquilizers 2,622 2.1 801 0.6

 Stimulants/Methamphetamine 1,677 1.3 599 0.5

 Sedatives 519 0.4 250 0.2 

Any Tobacco 34,751 27.4 29,484 23.3 

Alcohol 79,140 62.5 57,283 45.2 

Binge Alcohol Use — — 19,276 15.2 

Heavy Alcohol Use — — 4,172 3.3 

Source: SAMHSA 2007. 

Patterns of Use: From Initiation to Treatment 29 
higher number of pregnancies, less prenatal 

care, greater likelihood of substance use among 

family and friends, and greater severity of 

substance use (Derauf et al. 2007; Shieh and 

Kraavitz 2006). Continued substance abuse 

during pregnancy is a major risk factor for 

fetal distress, developmental abnormalities, 

and negative birth effects. It is also associated 

with delayed prenatal care, and it is quite likely 

that this delay is exacerbated as a result of 

fears pertaining to potential legal consequences 

(Jessup et al. 2003). Timely prenatal care for 

pregnant women who continue to use illicit drugs 

provides a significant buffer against adverse 

pregnancy outcomes, including premature 

births, small for gestational age status, and 

low birth weight (El-Mohandes et al. 2003; 

Quinlivan and Evans 2002). 

Prevalence of Substance 

Abuse and Dependence 

Among Women 

The Shrinking Gender Gap of 

Substance Abuse and Dependence 

Even though studies have consistently shown a 

greater prevalence of substance use disorders 

among men, evidence is also mounting on the 

narrowing of the gender gap for these disorders 

(see Figure 2-3 on p. 31). According to the 

NSDUH 2006 survey, females were as likely as 

males to abuse or be dependent on substances 

between 12 and 17 years of age, while older 

adolescent males and females continue to show a 

greater gender gap in percentages of substancerelated disorders. In comparing epidemiologic 

surveys from 1992 to 2002, an analysis found 

a significant increase in risk for alcohol abuse 

and dependence among women born after 1944, 

except for African-American women (Grucza et 

al. 2008). 

Across the Life Span 

As women become older, the prevalence of 

substance abuse and dependence becomes lower 

(Grant et al. 2006). The 2003 NSDUH estimated 

that 15.7 percent of women ages 18 to 25 abused 

or were dependent on alcohol or an illicit drug 

in the past year compared with 1.5 percent 

of those ages 50 or older (see Figure 2-4 on p. 

32). However, it is important to remember that 

women remain vulnerable to substance use, 

abuse, and dependence and its consequences 

across their life spans. As women encounter 

major life transitions, they are at a heightened 

risk for substance use and abuse (Poole and Dell 

2005). 

30 Patterns of Use: From Initiation to Treatment 

Figure 2-2 

Past-Month Substance Use, Based on Combined 2006 and 2007 Data: 

National Survey on Drug Use and Health (NSDUH), 2007 

Pregnant, Aged 15–44 Not Pregnant, Aged 15–44 

Any alcohol use 11.6 percent 53.2 percent 

Binge alcohol use 3.7 percent 24.1 percent 

Any illicit drug use 5.2 percent 9.7 percent 

Cigarette use 16.4 percent 28.4 percent 

Source: SAMHSA 2008. 
Characteristics of Treatment 

Admissions Among Women 

Data from treatment admissions provides 

considerable information on the patterns of 

substance use among women. Yet caution needs 

to be taken when generalizing this information 

across the entire population of women who have 

substance use disorders, since most women 

who have substance use disorders never receive 

treatment. According to TEDS data (SAMHSA 

2004), women are less likely to report alcohol 

as their primary substance of abuse compared 

with males. Although alcohol is still the primary 

substance of abuse, women are more likely than 

men to be in treatment for drug use. For women, 

37 percent report that opiates (20 percent) 

or cocaine (17 percent) are their primary 

substances of abuse. 

While women often receive other healthcare 

services prior to identification of substance use 

disorders, referrals from healthcare providers 

(other than alcohol and drug use treatment 

providers) are one of the lowest referral routes 

to treatment for women. Currently, self-referral, 

social service agencies, and the criminal justice 

system are the primary sources of referral to 

treatment for women (Brady and Ashley 2005; 

SAMHSA 2004). In comparison to men, women 

are more likely to be identified with a substance 

use disorder through child protective services 

(Fiorentine et al. 1997). 

Women who enter treatment are more likely to 

identify stress factors as their primary problem 

rather than substance use (Green et al. 2002; 

Thom 1987). They also exhibit more severity 

and problems related to substance use upon 

entering substance abuse treatment, including 

medical and psychological problems (Arfken 

et al. 2001). This heightened level of severity 

and symptomotology may, in part, be a result 

of delayed access to treatment due to various 

barriers, a reflection of rapid progression from 

initiation to alcohol and drug use consequences 

(telescoping), a manifestation of a woman’s 

tendency to consume alcohol and use cocaine 

more frequently than men (Pettinati et al. 

2000), or the lack of appropriate screening or 

identification of treatment need until severity is 

paramount. 

In Figure 2-5 (p. 33), the percentage of female 

admissions to substance abuse treatment 

Figure 2-3 

Percentages of Past-Year Abuse of or Dependence on Alcohol or Any 

Illicit Drug by Gender and Age, 2006 

Source: SAMHSA 2007. 

Patterns of Use: From Initiation to Treatment 31 
Figure 2-4 

Percentages of Past-Year Abuse of or Dependence on Alcohol or Any 

Illicit Drug Among Women Aged 18 or Older by Age Group: 2003 

Source: SAMHSA 2007. 

programs by racial/ethnic groups is shown. 

For more detailed information on ethnicity 

and substance abuse, refer to chapter 6. In 

addition, the planned TIP, Improving Cultural 

Competence in Substance Abuse Treatment 

(CSAT in development a) provides additional 

information on ethnicity and substance abuse 

patterns. 

TEDS data also provide information about 

substance preferences for women of specifi c 

population/ racial/ethnic groups. Figure 2-6 

shows the percentage of treatment admissions 

by substance for each ethnic or racial group of 

women. Except for the “alcohol plus another 

substance” category, only the woman’s primary 

substance of abuse is indicated in the table; 

the prevalence of polydrug abuse cannot be 

determined (SAMHSA 2004). 

As Figure 2-6 (p. 34) indicates, the primary 

substance of abuse reported on admission of 

Caucasian and American-Indian/Alaska-Native 

women is alcohol. Asian- and Pacifi c-American 

women reported methamphetamine most 

often. African-American women were more 

likely to name crack/cocaine as the primary 

substance of abuse, whereas some subgroups 

of Hispanic/Latina women were more likely to 

enter treatment for heroin use. For most ethnic 

or racial groups, alcohol and a secondary drug 

were abused by the next largest percentage of 

women. 

In 2002, women constituted about 30 percent 

of admissions for substance abuse (Brady and 

Ashley 2005), but they represented a larger 

proportion of admissions for prescription 

and over-the-counter (OTC) drug abuse (46 

percent; OAS 2004b). Depending on treatment 

level, admission rates varied from 29 percent 

in hospital inpatient facilities to 39 percent 

in outpatient methadone programs. Women 

were admitted in notable proportions for all 

types of prescription and OTC drug abuse: 47 

32 Patterns of Use: From Initiation to Treatment 
percent for prescription narcotics, 44 percent 

for prescription stimulants, 50 percent for 

tranquilizers, 51 percent for sedatives, and 

42 percent for OTC medications (OTC drugs 

include aspirin, cough syrup, and any other 

medication available without prescription). The 

majority of individuals admitted for prescription 

and OTC drug treatment were Caucasian (88 

percent; OAS 2004b). 

According to TEDS data (OAS 2004c), 15,300 

(4 percent) of women admitted to substance 

abuse treatment in 2002 were pregnant at the 

time of admission. Compared with the women in 

treatment who were not pregnant at admission, 

the pregnant women in treatment were more 

likely to report cocaine/crack (22 versus 17 

percent), amphetamine/methamphetamine (21 

versus 13 percent), or marijuana (17 versus 13 

percent) as their primary substance of abuse. 

Alcohol was the primary substance of abuse 

among almost one-third of women aged 15 to 

44 (31 percent) who were not pregnant at the 

time of admission. In contrast, only 18 percent 

of women who were pregnant at admission 

reported alcohol as their primary substance of 

abuse. 

Figure 2-5 

Percentage of Admissions to Substance Abuse Treatment 

Programs by Racial/Ethnic Group in 2006 

Group Percentage of Total Admissions 

Female Admissions 31.8

 Caucasian 20.1

 African American 6.4 

Hispanic (Mexican Origin) 1.6 

Hispanic (Puerto Rican Origin) 0.8 

American Indian/Alaska Native 0.9

 Asian/Pacifi c Islander 0.4 

Source: HHS, SAMHSA, OAS 2008 

Patterns of Use: From Initiation to Treatment 33 
Note to Clinicians 

For a woman entering treatment, the tendency to focus on problems or stressors other than 

her substance abuse is quite normal. Women are socialized to assume more caregiver roles 

and to focus attention on others. Even if she has not appropriately cared for others (such as 

her children) during her addiction, it does not mean that she will not see this as an important 

issue immediately upon entering a detoxification or treatment program. The clinician needs to 

appreciate this gender difference; instead of assuming that the client’s worries and her tendency 

to be other-focused is a detriment or an issue of resistance for treatment, use the client’s concerns 

as a means of motivation throughout treatment. 

Figure 2-6 

Primary Substance of Abuse Among Women Admitted for 

Substance Abuse Treatment by Racial/Ethnic Group by Percentage 

Hispanic Hispanic American Asian/ TWO 

Substance Cauca­ African (Mexi­ (Puerto Indian/ Pacifi c OR 

of Abuse sian American can Rican Alaska Island­ MORE 

Origin) Origin) Native er RACES 

Alcohol 35.5 24.8 22.6 20.4 39.5 26.4 21.7 

Cocaine/crack 13.3 35.0 12.0 18.4 8.0 9.2 12.0 

Heroin 12.7 16.3 11.8 38.5 9.7 8.2 5.7 

Other opioids 7.7 1.3 1.7 1.8 4.7 3.1 4.0 

Marijuana/hashish 11.8 17.6 15.6 15.2 10.2 16.3 19.4 

Methamphetamines 13.3 1.7 34.0 2.2 25.2 33.1 31.9 

Benzodiazepines 1.0 0.2 0.1 0.4 0.4 0.3 0.6 

Other amphetamines 0.6 0.1 0.3 0.1 0.5 0.7 0.8 

Other sedatives/ 

hypnotics 0.4 0.1 0.3 0.1 0.2 0.1 0.2 

Hallucinogens 0.1 0.1 0.1 0.1 0.1 0.2 0.1 

PCP 0.0* 0.4 0.5 0.3 0.1 0.2 0.2 

Inhalants 0.1 0.1 0.2 0.0* 0.2 0.1 0.2 

Over-the-counter 

(OTC) medications 0.1 0.0* 0.1 0.0* 0.1 0.1 0.1 

* Less than 0.05 percent 

Source: HHS, SAMHSA, OAS 2008. 

34 Patterns of Use: From Initiation to Treatment 
Advice to Clinicians and Administrators: 

Using Patterns of Use as a Clinical Guide 

For Clinicians: 

• Foremost, it is important to remember that women are as likely as men to become

addicted to alcohol and drugs if given an opportunity. By making an assumption that 

women are less likely to have a substance use disorder, important information may 

not be obtained in the screening and assessment process, thus leading to misdiagnosis 

or under diagnosis. 

• Depending on the specific drug class, some women may have considerable concerns 

regarding potential weight gain if they enter treatment and establish abstinence. 

Among women, weight loss is more likely a major benefit in continuing drug use. 

• In assessing risk factors or potential triggers for relapse, don’t underestimate that 

the initial reasons for use may be the same reasons for relapse, even if initial use 

occurred many years ago. As a clinician, it is important to prepare for a premature 

termination of treatment and establish an intervention plan tailored to address these 

initial reasons for use. More times than not, women generally will underestimate the 

risks associated with these issues. For example, women who initiated use due to a 

relationship will often deny that relationships are a current risk factor. Nonetheless, 

the counselor should not immediately follow the client’s self-assessment but rather 

proceed with creating roleplays that simulate possible scenarios to provide practice 

in how to handle relationship issues before they actually occur in treatment; i.e., 

roleplay a telephone call from a boyfriend who believes that the client does not have 

a problem and begs her to come home. More often than not, other women in the 

treatment group have a better handle on the actual scenarios that are high risk for 

each other. 

• Remember that women are socialized to be other-focused. Just because they may not 

have attended to some of their responsibilities during active substance use does not 

mean that they will not be focused on these responsibilities upon entering treatment. 

Rather than pushing the idea that they need to “get their head into treatment and 

not be so focused on outside issues,” use their ability to be other-focused as a tool in 

developing motivation for recovery. Assuming that a woman is resistant to treatment 

because she is other-focused in the program is a form of gender bias. Women are 

socialized to think about others. 

• Because substance abuse tends to run in families, a woman’s parents and children 

as well as her partner need to be considered in planning treatment. As important, a 

woman needs to be aware of the influence of substance abuse in her family. Using a 

family geneogram or family tree to mark who has used substances can be a valuable 

tool in assessing the degree of influence in her family. 

• A partner’s substance use and attitudes toward substance use can infl uence a 

woman’s substance use. A woman who uses illicit drugs is more likely to have a 

partner who also uses illicit drugs. The counselor should work with all individuals who 

have influence on the client so that each person develops attitudes and behaviors 

that will be supportive of the client’s recovery. 

• Remember to assess for personality traits that are more conducive to substance abuse

among women, namely sensation-seeking. 

Patterns of Use: From Initiation to Treatment 35 
Advice to Clinicians and Administrators: 

Using Patterns of Use as a Clinical Guide (continued) 

• 	 Trauma is both a risk factor for and a consequence of substance abuse. Women with 

histories of trauma may be using substances to self-medicate symptoms. Subsequently, 

interventions should be immediately put into place to help build coping strategies to 

manage strong affect, including relaxation training and other anxiety management 

skills. Start skills-building immediately rather than waiting for an incident to occur. It 

is far more difficult to manage symptoms when they are heightened than when they 

are at lower levels of intensity. 

• 	 From the outset, counselors need to be aware of the potential and common 

occurrence and impact of co-occurring disorders among women with substance use 

disorders, especially mood, anxiety, and eating disorders. 

For Administrators: 

• 	 Administrators need to develop and incorporate policies and procedures that support 

family involvement from the onset. Beginning with the initial contact, staff need 

to convey the importance of family involvement and the program’s expectations 

regarding the necessity of family participation. 

• 	 Adminstrators need to develop policies and procedures to address co-occurring issues, 

including screening, assessment, and referral processes. They need to secure funding 

and endorse programs that are effective with various populations, such as traumainformed services and culturally responsive programs. 

36 Patterns of Use: From Initiation to Treatment 
In This
 

Chapter
 

Physiological Effects 


and Consequences of 


Substance Abuse in 


Women
 

Physiological Effects: 


Factors of Infl uence
 

Physiological Effects 


of Alcohol
 

Physiological Effects 


of Licit and Illicit 


Drugs
 

Physiological Effects 


of Tobacco Use
 

Effects of Alcohol, 


Drugs, and Tobacco 


on Pregnancy and 


Birth Outcomes
 

Effects of Alcohol and 


Illicit Drugs on HIV/
 

AIDS Status
 

3 Physiological 

Effects of Alcohol, 


Drugs, and Tobacco 


on Women 

Overview 

Based on human and animal studies, women are more sensitive to 

the consumption and long-term effects of alcohol and drugs than 

men. From absorption to metabolic processes, women display more 

difficulty in physically managing the consequences of use. In general, 

with higher levels of alcohol and drugs in the system for longer 

periods of time, women are also more susceptible to alcohol- and 

drug-related diseases and organ damage. 

This chapter provides an overview of the physiological impact 

of alcohol and drugs on women, with particular emphasis on the 

significant physiological differences and consequences of substance 

use in women. It begins with a general exploration of how gender 

differences affect the way alcohol and drugs are metabolized in 

the body and then highlights several biopsychosocial and cultural 

factors that can influence health issues associated with drugs and 

alcohol. The chapter goes on to explore the physiological effects of 

alcohol, drugs (both licit and illicit), and tobacco on the female body. 

A summary of key research on the impact of these substances when 

taken during pregnancy follows, and the chapter closes with a review 

of the effect that substance abuse has on women’s HIV/AIDS status. 

Counselors can use the information presented in this chapter to 

educate their female clients about the negative effects substances can 

have on their physical health. A sample patient lecture is included 

that highlights the physiological effects of heavy alcohol use. 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 37 
Physiological Effects 

and Consequences of 

Substance Abuse in 

Women 

Alcohol and drugs can take a heavy toll on the 

human body. The same general statements can 

be made for both men and women about their 

long-term effects—for example, both genders 

incur liver problems resulting from alcohol 

abuse, respiratory impairment and lung cancer 

as a consequence of smoking, HIV/AIDS and 

hepatitis from injection drug use, and memory 

difficulties associated with the use of marijuana. 

Yet women have different physical responses to 

substances and greater susceptibility to healthrelated issues. Women differ from men in the 

severity of the problems that develop from use of 

alcohol and drugs and in the amount of time between initial use and the development of physiological problems (Greenfield 1996; Mucha et al. 

2006). For example, a consequence of excessive 

alcohol use is liver damage (such as cirrhosis) 

that often begins earlier in women consuming 

less alcohol over a shorter period of time. By 

and large, women who have substance use disorders have poorer quality of life than men on 

health-related issues. 

In addition, women who abuse substances have 

physiological consequences, health issues, and 

medical needs related to gynecology (Peters et 

al. 2003). Specifically, drugs and alcohol affect 

women’s menstrual cycles, causing increased 

cramping and heavier or lighter periods. Women 

sometimes use illicit drugs and alcohol as medication for cramping, body aches, and other discomforts associated with menstruation (Stevens 

and Estrada 1999). On the other hand, women 

who use heroin and methadone can experience 

amenorrhea (absence of menstrual periods; Abs 

et al. 2000), leading them to believe that they are 

unable to conceive and misreading early signs 

of pregnancy as withdrawal symptoms. Subsequently, they are unaware that they are pregnant. Women’s substance use also poses risks to 

fetuses and nursing infants. 

Limitations of Current Research on 

Gender Differences in Metabolism 

In general, research on the unique physiological 

effects of alcohol and drugs in women is limited and sometimes inconclusive. Although the 

differences in the way women and men metabolize alcohol have been studied in some depth, 

research on differences in metabolism of illicit 

drugs is limited. For many years, much of the 

research on metabolism of substances either 

used male subjects exclusively or did not report 

on gender differences. Historically, women were 

omitted due to the potential risk of pregnancy 

and the possibility that hormonal changes across 

the menstrual cycle would wreak havoc on the 

drugs’ effects and subsequent results. 

Available research is typically based on small 

sample sizes and has not been replicated. Race 

and ethnic background can affect metabolism 

and the psychological effects of alcohol and illicit drugs, as can the psychopharmaceuticals 

sometimes used in treatment (Rouse et al. 1995), 

but their effects have not been studied. Similar 

to men, few women abuse only one substance. 

Polysubstance use complicates the ability to 

study and understand the physiological effects 

of specific drugs on women, while increasing 

the risk associated with synergistic effects when 

substances are combined. Significant gaps in 

knowledge exist regarding physiological effects 

across the continuum of a woman’s life. 

Physiological Effects: 


Factors of Infl uence
 

Ethnicity and Culture 

The level of acculturation and cultural roles and 

expectations play a significant role in substance 

use patterns among women of color (Caetano 

et al. 2008). The prevalence of substance abuse 

among ethnic women typically coincides with 

higher levels of acculturation in the United 

States, thus leading to greater health issues. 

Literature suggests that women from ethnically 

diverse backgrounds who have substance use 

38 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
disorders possess greater risks for developing 

certain conditions and disorders, such as hypertension, high blood pressure, and HIV/AIDS 

(Centers for Disease Control [CDC] 2000a, b; 

Steffens et al. 2006; Vernon 2007). These health 

disparities arise from many sources, including 

difficulty in accessing affordable health care, 

delays in seeking treatment, limited socioeconomic resources, racism, and discrimination 

(Gee 2002; Mays et al. 2007; Williams 2002). 

In addition, mistrust of health care providers 

is a significant barrier to receiving appropriate 

screening, preventive care, timely interventions, 

and adequate treatment (Alegria et al. 2002). 

More recent studies have explored the role of 

gender in perceived discrimination and health, 

and some studies have noted differences in the 

type of stressors, reactions, and health consequences between men and women (Finch et al. 

2000; Flores et al. 2008). For example, the Black 

Women’s Health Study found that perceived 

experiences of racism were associated with an 

increased incidence of breast cancer (Taylor et 

al. 2007). 

Sexual Orientation 

Lesbian/bisexual women exhibit more prevalent 

use of alcohol, marijuana, prescription drugs, 

and tobacco than heterosexual women, and they 

are likely to consume alcohol more frequently 

and in greater amounts (Case et al. 2004; Cochran et al. 2001, 2004). Based on the Substance 

Abuse and Mental Health Services Administration’s (SAMHSA’s) 1996 National Household 

Survey on Drug Abuse, researchers compared 

patterns of use between homosexual and heterosexual women and found that lesbians have 

greater alcohol-related morbidity (Cochran et 

al. 2001). Likewise, they are less likely to have 

health insurance and to use preventive screenings, including mammograms and pelvic examinations. With less utilization of routine screenings, lesbians and bisexual women may not be 

afforded the benefit of early detection across 

disorders, including substance use disorders, 

breast cancer, and cardiovascular disease. 

Socioeconomic Status and 

Homelessness 

Overall, lower socioeconomic status is associated 

with higher mortality rates and greater risks for 

cervical cancer, coronary heart disease, HIV/ 

AIDS, and other health conditions and medical 

disorders (Adler and Coriell 1997). More than 

ethnicity, socioeconomic status heavily infl uences the health risks associated with substance 

abuse. Research suggests that when the socioeconomic conditions of ethnically diverse populations are similar to those of the White population, consequences of substance use appear 

comparable (Jones-Webb et al. 1995). Among 

women, alcohol and drug-related morbidity 

and mortality are disproportionately higher in 

individuals of lower socioeconomic status, which 

is associated with insufficient healthcare services, difficulties in accessing treatment, lack of 

appropriate nutrition, and inadequate prenatal 

care. Subsequently, impoverished women who 

abuse substances often experience greater health 

consequences and poorer health outcomes. 

Similarly, homelessness is associated with higher 

mortality rates for all life-threatening disorders, 

including greater risks for infectious diseases. 

With greater high-risk sexual behaviors and repeated exposure to overcrowded shelters, homeless women who use injection drugs are more 

likely to be infected with HIV/AIDS and other 

infectious diseases, including airborne infections 

such as tuberculosis, thereby leading to greater 

health consequences (for review, see Galea and 

Vlahov 2002). 

Developmental Issues and Aging 

Although little is known regarding the effect of 

alcohol and drugs on development across the 

lifespan, there is some evidence in alcohol-related research that there are different vulnerabilities at different ages for women. Even though 

developmental research on alcohol is not easily 

transferred to other drugs of abuse, it can give 

us a glimpse of the potential physiological issues 

associated with age and aging. For example, adolescent women are more likely than their male 

counterparts to experience cognitive impairment 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 39 
despite less alcohol consumption. Women of 

child-bearing age are more likely to experience 

infertility with heavier drinking (Tolstrup et al. 

2003). Postmenopausal women are more likely 

to exhibit significant hormonal changes with 

heavy consumption of alcohol, leading to potentially higher risks for breast cancer, osteoporosis, and coronary heart disease (Weiderpass 

et al. 2001). Older women are more sensitive to 

alcohol and display a decrease in tolerance and 

alcohol metabolism (Center for Substance Abuse 

Treatment [CSAT] 1998d). While research has 

been more devoted to examining gender differences, limited data are available for other 

substances and less is known regarding the effect 

of these substances on development and aging. 

Co-Occurring Disorders: A 

Bidirectional Infl uence 

According to SAMHSA’s National Survey on 

Drug Use and Health (NSDUH) report (Offi ce 

of Applied Studies [OAS] 2004b), women with 

co-occurring mental and substance use disorders 

are likely to experience serious physical health 

problems. Co-occurring disorders have a bidirectional relationship and often a synergistic effect on one another. As much as substance abuse 

can increase the risk of, exacerbate, or cause 

medical conditions, medical disorders can also 

increase substance abuse as a means of self-medicating symptoms or mental distress associated 

with the disorder. Similar to men, women who 

have mental disorders can have more diffi culty 

adhering to health-related treatment recommendations, such as treatment attendance, diet 

restrictions, or medication compliance. 

Physiological Effects of 

Alcohol 

Gender Differences in Metabolism 

and Effects 

Alcohol is a leading cause of mortality and 

disability worldwide. According to the World 

Health Organization, alcohol is one of the fi ve 

most significant risk factors for diseases, with 

more than 60 percent of alcohol-related diseases 

being chronic conditions, including cancer, cirrhosis of the liver, diabetes, and cardiovascular 

disease (Chisholm et al. 2004). 

Alcohol’s effects on women have been studied 

more than those of illicit drugs. Compared with 

men, women become more cognitively impaired 

by alcohol and are more susceptible to alcoholrelated organ damage. Women develop damage 

at lower levels of consumption over a shorter 

period of time (for review, see Antai-Otong 

2006). When men and women of the same weight 

consume equal amounts of alcohol, women have 

higher blood alcohol concentrations. Women 

have proportionately more body fat and a lower 

volume of body water compared with men of 

similar weight (Romach and Sellers 1998). As 

a result, women have a higher concentration of 

alcohol because there is less volume of water to 

dilute it. 

In comparison with men, women, at least those 

younger than 50, have a lower fi rst-pass metabolism of alcohol in the stomach and upper small 

intestine before it enters the bloodstream and 

reaches other body organs, including the liver. 

One researcher concluded that women’s lack 

of a functional gastric protective barrier means 

that “for an alcoholic woman to drink alcohol 

is the same as taking the alcohol directly into a 

vein,” contributing to her greater vulnerability 

to alcohol-related organ damage (Lieber 2000, p. 

417). 

These factors may be responsible for the increased severity, greater number, and faster rate 

of development of complications that women 

experience from alcohol abuse when compared 

with men, according to reviews of several studies 

(Blum et al. 1998; Greenfield 1996). Women develop alcohol abuse and dependence in less time 

than do men, a phenomenon known as telescoping (Piazza et al. 1989). At a rate of consumption 

of two to three standard drinks per day, women 

have a higher mortality rate than men who drink 

the same amount. Men do not experience an 

increased mortality risk until they consume four 

drinks daily (Holman et al. 1996). 

40 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
Women develop other alcohol-related diseases at 

a lower total lifetime exposure than men, including such disorders as fatty liver, hypertension, 

obesity, anemia, malnutrition, gastrointestinal 

hemorrhage, and ulcers that require surgery 

(Van Thiel et al. 1989). Heavy alcohol use also 

increases the risk of hemorrhagic stroke, according to one study cited by Nanchahal and 

colleagues (2000). Older women respond to 

alcohol somewhat differently than do younger 

women. They have even less body water, a 

heightened sensitivity to and decreased tolerance 

for alcohol, and a decrease in alcohol metabolism in the gastrointestinal tract (CSAT 1998d). 

The following sections identify specifi c physiological effects related to alcohol use by women. 

These effects are not distinct from one another; 

rather, they interact in a synergistic way in the 

body. 

Liver and Other Organ Damage 

Females are more likely than their male counterparts to experience greater organ damage as a 

result of consuming similar amounts of alcohol. 

Compared with men, women develop alcoholinduced liver disease over a shorter period of 

time and after consuming less alcohol (Gavaler 

and Arria 1995). Women are more likely than 

men to develop alcoholic hepatitis and to die 

from cirrhosis (Hall 1995). One researcher has 

theorized that women’s faster alcohol elimination rate can endanger the liver by subjecting it 

to high, though transient, levels of acetaldehyde, 

a toxic byproduct of alcohol metabolism. This 

exposure may explain the higher liver cirrhosis 

rates among women (e.g., Thomasson 2000). 

Cardiac-Related Conditions 

According to current studies, women who drink 

exhibit a greater propensity to develop alcoholinduced cardiac damage. While light consumption (less than one drink per day) can serve as 

a protective factor for women who have a risk 

for coronary artery disease, studies suggest that 

protection is not evident for younger women, 

women who drink heavily, and women without 

risk factors associated with heart disease. Women who are dependent on alcohol or consume 

heavier amounts are more likely to die prematurely from cardiac-related conditions (Bradley 

et al. 1998a; Fernandez-Sola and Nicolas-Arfelis 

2002; Hanna et al. 1992). 

Heavy consumption (more than four drinks per 

day) is associated with increased blood pressure 

in both women and men (Bradley et al. 1998a). 

A major epidemiological study found that women between ages 30 and 64 who consumed 15–21 

units of alcohol per week had an increased risk 

of hypertension compared with those who drank 

14 or fewer units; those who drank 1–7 units per 

week had an overall decrease in 10-year risk of 

cardiovascular disease compared with those who 

drank more (Nanchahal et al. 2000). The female 

heart appears to experience a functional decline 

at a lower level of lifetime exposure to alcohol 

than does the male heart (Urbano-Marquez et 

al. 1995). 

What constitutes light, moderate, or heavy 

drinking? 

The U.S. Department of Health and Human 

Services and U.S. Department of Agriculture’s definition of moderate alcohol consumption (2005) varies by gender: In women, 

moderate drinking is considered to be no more 

than one drink per day, compared with no 

more than two drinks per day for men. These 

differences stem from gender differences in 

body composition and metabolism. 

Reproductive Consequences 

Research into the adverse impact of alcohol consumption on fertility is growing. While numerous studies have shown a consistent relationship 

between heavy drinking and infertility (Eggert 

et al. 2004; Tolstrup et al. 2003), additional 

studies examining moderate consumption are 

more inconsistent. Nevertheless, fi ndings suggest 

a need to educate and screen women for alcohol 

use while they are seeking infertility treatment 

(Chang et al. 2006). In addition, heavy drinking is associated with painful and/or irregular 

menstruation (Bradley et al. 1998a). The reproPhysiological Effects of Alcohol, Drugs, and Tobacco on Women 41 
ductive consequences associated with alcohol use 

disorders range from increased risk for miscarriage to impaired fetal growth and development 

(Mello et al. 1993). 

There are considerable variations among women 

in their capacity to consume and metabolize 

alcohol. Early literature suggests that variations 

in alcohol metabolism among women may be 

linked to the different phases of the menstrual 

cycle, but more recent reviews suggest that there 

are no consistent effects of the menstrual cycle 

on the subjective experience of alcohol intake or 

alcohol metabolism (Terner and de Wit 2006). 

Studies reviewed by Romach and Sellers (1998) 

found that significant hormonal changes are reported in postmenopausal women who consume 

alcohol. Women taking hormone replacement 

therapy (HRT), now referred to as menopausal 

hormone therapy, and consuming 14 or more 

standard drinks weekly had signifi cantly higher 

estradiol levels. These high levels are associated 

with a greater risk of breast cancer and coronary heart disease. 

Breast and Other Cancers 

Numerous studies have documented associations 

and suggested causal relationships between alcohol consumption and breast cancer risk (Key 

et al. 2006; Li et al. 2003; Zhang et al. 2007). 

A review of data from more than 50 epidemiological studies from around the world revealed 

that for each drink of alcohol consumed daily, 

women increased their risk of breast cancer by 7 

percent (Hamajima et al. 2002). Postmenopausal 

women have an increased risk of breast cancer 

as well if they currently drink alcohol (Lenz et 

al. 2002; Onland-Moret et al. 2005). Women who 

drink alcohol have elevated estrogen and androgen levels, which are hypothesized to be contributors to the development of breast cancer in 

this population (Singletary and Gapstur 2001). 

In addition, postmenopausal women who are 

moderate alcohol drinkers (one to two drinks a 

day) and who are using menopausal hormone 

therapy have an increased risk of breast cancer, 

with even greater risk at higher rates of alcohol 

consumption (Dorgan et al. 2001; Onland-Moret 

et al. 2005). 

While the risk for in situ and invasive cervical 

cancer and cancer of the vagina may be associated with other environmental factors including 

high-risk sexual behavior, human papilloma viruses, smoking, hormonal therapy, and dietary 

deficiency, Weiderpass and colleagues (2001) 

concluded, based on 30 years of retrospective 

data, that women who are alcohol dependent are 

at a higher risk for developing these cancers. 

Similarly, Bagnardi et al. (2001) conducted a 

meta-analysis of more than 200 studies whereby 

they found that alcohol signifi cantly increased 

the risks for cancers of the oral cavity, pharynx, 

esophagus, larynx, stomach, colon, rectum, 

liver, and ovaries. Although further investigation is needed to explore the role of alcohol 

consumption on gastric cancer, preliminary 

findings suggest that the type of alcoholic beverage, namely medium-strength beer, creates an 

increased risk of gastric cancer (Larsson et al. 

2007). Based on a multiethnic cohort study, the 

risk of endometrial cancer increases when postmenopausal women consume an average of two 

or more drinks per day (Setiawan et al. 2008). 

Additional risks are associated with tobacco use, 

particularly for cancers of the upper digestive 

and respiratory tract. 

Osteoporosis 

According to Bradley and colleagues (1998a), 

evidence suggests “decreased bone formation and abnormal vitamin D metabolism may 

predispose alcohol-dependent premenopausal 

women to osteoporosis” (p. 631). Heavy alcohol 

use clearly has been shown to harm bones and to 

increase the risk of osteoporosis by decreasing 

bone density. These effects are especially striking in young women, whose bones are developing, but chronic alcohol use in adulthood also 

harms bones (Sampson 2002). In addition, animal studies suggest that the damaging effects of 

early chronic alcohol exposure are not overcome 

even when alcohol use ceases (Sampson 1998). 

Tobacco use also may increase the risk of osteoporosis and fractures; people who drink are 75 

percent more likely to smoke, and people who 

42 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
 

Clinical Activity: Sample Client-Educating Lecture Outline for 

Counselors Physiological Effects of Alcohol 

This 60-minute lecture provides a general outline highlighting the physiological effects of moderate-to-heavy alcohol use. Refer to this TIP chapter for additional information to support your 

lecture. To increase participation, first ask women in the group to identify medical problems 

they believe to be related to their alcohol use. The format of this lecture can also be used with 

illicit and prescription drugs. Many conditions do occur in men, but it is important to emphasize 

the enhanced risk and the earlier appearance of these diseases and conditions among women. 

The list of physiological consequences identifies the most common disorders; it is not intended as 

a comprehensive review. 

I. 	 Rationale: Women’s positive response to health education 

II. 	Objectives: 

A. 	To review what constitutes moderate-to-heavy drinking among women 

B. 	To describe physiological differences in how alcohol is metabolized in a woman’s body 

C. 	To explore the long-term consequences of drinking, with emphasis on specifi c consequences unique to women 

III. Equipment: Using an easel with newspaper print or a board, draw a human body. As you 

lecture, write in the effects of alcohol on the body to demonstrate how dramatically alcohol 

affects women. At the end of the lecture, the body should be covered with physiological consequences. 

IV. Definition: In women, moderate drinking is considered to be no more than one drink per 

day (U.S. Department of Health and Human Services and U.S. Department of Agriculture 

[2005]). 

V.	 Alcohol Metabolism and Women: 

A. 	Women have higher blood alcohol concentrations after drinking the same amount of 

alcohol as men. 

B. 	Women have more body fat and a lower volume of body water than men of equal weight. 

Consequently, women are less able to dilute alcohol once it enters the body, and this 

leads to a higher concentration of alcohol in the bloodstream and organs. 

C. 	Women have a lower concentration of gastric dehydrogenase, an enzyme responsible for 

metabolism. Because alcohol takes longer to metabolize in women, it has more deleterious effects on major organs for a longer period of time. Longer metabolism and less dilution is a potent mixture for women! In addition, women have smaller organs than men, 

causing greater vulnerability to the long-term effects of alcohol. 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 43 
Clinical Activity: Sample Client-Educating Lecture Outline for 

Counselors Physiological Effects of Alcohol (continued) 

VI. Long-Term Consequences: Women experience negative physical consequences and complications from alcohol sooner and at lower levels of consumption than men. Evidence suggests 

that women progress significantly faster in developing dependence, organ damage, and 

diseases with much lower levels of alcohol consumption. Women are more likely to die many 

years earlier from alcohol abuse and dependence. 

A. 	Liver and Other Gastrointestinal Disorders 

1. Fatty Liver 

2. 	 Alcohol Hepatitis 

3. 	 Cirrhosis 

4. 	 Liver Cancer 

5. 	 Ulcers/Gastritis 

6. 	 Pancreatitis 

7. 	 Diabetes 

B. 	Cardiac-Related Conditions 

1. 	 High Blood Pressure (hypertension) 

2. 	 Cardiomyopathy 

3. 	 Stroke 

4. 	 Arrhythmia 

C. 	Nutritional Defi ciencies 

1. Malnutrition 

2. 	 Vitamin and Mineral Defi ciencies 

D. 	Reproductive Consequences 

1. 	 Fetal Alcohol Spectrum Disorders: Fetal alcohol syndrome, alcohol-related birth 

defects (ARBD), partial fetal alcohol syndrome (pFAS), and alcohol-related neurodevelopmental disorder (ARND) 

2. 	 Low Birth Weight 

3. 	 Miscarriage 

4. Painful/Irregular Menstruation 

5. 	 Underproduction of Hormones 

44 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
 

Clinical Activity: Sample Client-Educating Lecture Outline for 

Counselors Physiological Effects of Alcohol (continued) 

E. Breast and Other Cancers 

1. Breast Cancer 

2. Throat and Mouth Cancer 

3. Stomach and Colon Cancer 

4. Other Cancers 

F. Osteoporosis 

G. Cognitive and Other Neurological Effects 

1. Brain Shrinkage 

2. Peripheral Neuritis/Neuropathy 

3. Dementia 

4. Korsakoffs/Wernickes 

5. Cerebellar Degeneration 

H. Infections: Greater Susceptibility and Progression 

1. HIV/AIDS 

2. Tuberculosis 

3. Pneumonia 

I. Other Disorders and Conditions 

smoke are 86 percent more likely to drink (Shiffman and Balabanis 1995).Women in menopause 

who enter treatment need bone density assessment, nutritional guidelines, and medication 

consultations. 

Neurological Effects 

Starting with adolescence, women appear to be 

more susceptible to the toxic effects of alcohol 

or its metabolites on the nervous system and 

more vulnerable to alcohol-induced brain damage than men (Bradley et al. 1998a; Hommer et 

al. 1996; Mann et al. 2005; Mumenthaler et al. 

1999). Research supports that adult and adolescent women who are alcohol dependent experience greater declines in cognitive and motor 

function than men despite less alcohol consumption, shorter history of overall use, and shorter 

duration of alcohol dependence (Acker 1986; 

Flannery et al. 2007; Sullivan et al. 2002). 

In comparison with men who are alcohol dependent and female controls (women who are not 

dependent on alcohol), women who are alcohol 

dependent exhibit deterioration in planning, 

visuospatial ability, working memory, and psychomotor speed. They also show brain abnormalities and shrinkage after a shorter drinking history and lower peak consumption than 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 45 
do men. Studies demonstrate that in general, 

women with alcohol dependence disorders have 

significantly smaller volumes of gray and white 

matter, less hippocampal volume (memory), and 

greater peripheral neuropathy than either men 

who abused alcohol or women who did not abuse 

alcohol (Ammendola et al. 2000; Hommer et al. 

2001; Romach and Sellers 1998; Schweinsburg 

et al. 2003). 

Women appear to be at greater risk than men 

for Alzheimer’s disease, although women’s longer life spans may contribute to this higher risk 

(Sohrabji 2002). Heavy alcohol consumption 

is known to result in memory deficits and may 

increase the risk for Alzheimer’s disease in both 

genders, but particularly in women, who appear to be more vulnerable than men to alcoholinduced brain damage (Sohrabji 2002). 

Physiological Effects of 

Licit and Illicit Drugs 

Gender Differences in Metabolism 

and Effects 

Research (Hernandez-Avila et al. 2004) supports the concept of an accelerated progression 

to treatment entry among women dependent on 

opioids, cannabis, or alcohol, and suggests the 

existence of a gender-based vulnerability to the 

adverse consequences of these disorders. No 

gender difference was noted for age at onset of 

regular use, but the women had used opioids, 

cannabis, and alcohol for fewer years before 

entering treatment. The severity of drug and 

alcohol dependence did not differ by gender, but 

women reported more severe psychiatric, medical, and employment complications than did 

men. In one substance abuse treatment study 

focused on urban outpatient clinics, women had 

more symptoms than men across substances 

(Patkar et al. 1999). They reported more 

cardiovascular, mood, nose and throat, neurological, skin, and gastrointestinal symptoms 

than did men. In addition, there is evidence 

that women who use injection drugs are more 

susceptible to medical disorders and conditions 

(Zolopa et al. 1994). Similarly, women who 

use cocaine, heroin, or injection drugs have a 

heightened risk of developing herpes, pulmonary tuberculosis, and/or recurrent pneumonia 

(Thorpe et al. 2004). 

To date, little is known regarding the consequences of specific drug use among women. 

Complicated by polysubstance use, studies are 

often unable to obtain adequate sample sizes of 

women who abuse only one drug. The following 

section highlights specific physiological effects of 

licit and illicit drugs that are unique to women. 

This is not a general primer on drugs, but 

rather a compendium of known physiological 

effects that are gender-specifi c. 

Cocaine, Amphetamine, and 

Methamphetamine 

Hormonal changes across the menstrual cycle 

have the greatest effect on stimulant drugs, particularly cocaine and amphetamine. Literature 

highlights a consistent and greater mood-altering effect of stimulant use during the follicular 

phase of the cycle (for review, see Terner and de 

Wit 2006), and the fluctuations in progesterone 

levels may account, in part, for this sex difference (Evans 2007; Evans and Foltin 2006). 

More specifically, Evans and colleagues (2002) 

investigated whether cocaine effects vary as a 

function of menstrual cycle phase; they found 

that heart rate and ratings such as “good drug 

effect” were increased more during the follicular phase than the luteal phase. Conversely, 

injection drugs and/or crack cocaine appear to 

produce changes in the menstrual cycle, including the development of amenorrhea, degree of 

blood flow, and the intensity of cramps (Stevens 

and Estrada 1999). Overall, women who use 

cocaine report more positive subjective drug 

effects, including greater euphoria and desire 

to use, while physiological responses to the drug 

did not change (McCance-Katz et al. 2005). 

Methamphetamine use has an array of possible 

adverse effects (for review, see Winslow et al. 

2007), but data regarding specific gender differences are limited. Psychoactive effects of methylenedioxy- methamphetamine (ecstasy) have 

been found to be more intense in women than in 

46 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
men; women report experiencing a higher degree 

of perceptual changes, thought disturbances, 

and fear of the loss of control of their bodies. 

Acute adverse effects, such as jaw clenching, dry 

mouth, and lack or loss of appetite, are more 

common among women (Liechti et al. 2001). 

Heroin and Other Opioids 

Research is lacking that would allow defi nitive 

conclusions about gender similarities or differences in the following effects of heroin use: 

scarred and collapsed veins, bacterial infections 

of blood vessels and heart valves, abscesses, 

cellulitis, and liver or kidney disease (National 

Institute on Drug Abuse [NIDA] 2000). 

Research suggests that there are no menstrual 

cycle differences in women’s subjective experience or physiological reaction to opioids (Gear 

et al. 1996), but women using heroin or methadone do experience menstrual abnormalities, 

particularly amenorrhea or an irregular menstrual cycle (Abs et al. 2000; Santen et al. 1975; 

Smith et al. 1982). It can take up to a year for 

regular menstrual cycles to resume after drug 

use is stopped. Deficits in sexual desire and 

performance are also consequences of heroin 

use (Smith et al. 1982). These symptoms probably are related to the lower levels of luteinizing 

hormone, estradiol, and progesterone found 

in these women (Abs et al. 2000). Amenorrhea 

and other symptoms often make women believe 

they are permanently sterile, a fear that can be 

lessened with education. TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid 

Treatment Programs (CSAT 2005b) provides 

more information. 

Marijuana 

Studies on marijuana effects have not focused 

specifically on gender differences; therefore, 

little is known about how marijuana affects men 

and women differently. In studies evaluating 

hormonal changes and the physiological and 

psychological effects of marijuana use, fi ndings 

suggest that the effects of marijuana do not vary 

markedly across the menstrual cycle (Block et 

al. 1991; Griffin et al. 1986; Lex et al. 1984). 

Effects of marijuana on birth outcomes are discussed below. 

Prescription and Over-the-Counter 

Medications 

Women are significantly more likely to use 

and abuse prescription medications, including anxiolytics (antianxiety medications) and 

narcotic analgesics (pain medications), than are 

men (Simoni-Wastila 2000). Little research is 

available, however, on the gender differences 

and differential physiological effects of abuse of 

prescription medications. Moreover, research 

into the influence of hormonal changes across 

the menstrual cycle on subjective, behavioral, 

and physiological effects is limited to benzodiazepines, and findings are minimal (Bell et al. 

2004; Kamimori et al. 2000). 

Over-the-counter (OTC) medications include 

cold remedies, antihistamines, sleep aids, and 

other legally obtained nonprescription medications. It is not uncommon for individuals with 

eating disorders, particularly those diagnosed 

with bulimia nervosa, to abuse laxatives, diuretics, emetics, and diet pills. Misuse of these 

medications can result in serious medical complications for those with eating disorders, who 

primarily are women (U.S. Department of 

Health and Human Services, Office on Women’s 

Health 2000). Complications can involve the 

gastrointestinal, neuromuscular, and cardiac 

systems and can be lethal. Many prescription 

and OTC medications interact negatively with 

alcohol and drugs. 

Gender Differences and 

OTC Drugs 

Across studies, prevalence rates comparing the 

use and misuse of OTC medications among men 

and women vary according to age and race/ethnicity. For individuals 65 years of age and older, 

women are more likely to use OTC drugs (Halon 

et al. 2001). NSDUH evaluated the misuse of 

OTC cough and cold medications among persons 

aged 12 to 25 (SAMHSA 2007) and found that 

women aged 12 to 17 were more likely than men 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 47 
“Every woman is 	

different. No amount 

of drinking is 100 

percent safe, 100 	

percent of the time, 

for every individual 

woman” (National 

Institute on 

Alcohol Abuse and 

Alcoholism [NIAAA] 	

2003). 

to have misused OTC cough and cold medications in the past year, while men between 18 and 

25 years of age were more likely to have misused 

these medications. Whites and Hispanics had 

higher rates of misuse than African Americans. 

Similar to men, women who had ever misused 

OTC cough and cold medications also had lifetime use of marijuana and inhalants. In evaluating prescription and OTC drug treatment admissions, women represented a larger proportion 

of prescription and OTC 

medication admissions 

(46 percent) than treatment admissions for all 

substances (30 percent;

SAMHSA 2004). 

Physiological 

Effects of 

Tobacco Use 

The health risks associated with nicotine use 

are considerable, particularly among women.

In comparison with men, 

women who smoke show 

higher disease risk regardless of smoking level 

or intensity (Mucha et al. 

2006). Currently, cancer is the second leading

cause of death among 

women, with mortality 

rates higher for lung 

cancer than breast cancer. According to the Office of the Surgeon General (2001b), women who 

smoke: 

• 	Have an increased risk of peptic ulcers and 

Crohn’s disease. 

• 	Have an increased risk of estrogen defi ciency; 

difficult, irregular or painful menstruation; 

and amenorrhea. 

• 	Are more likely to be diagnosed with cancer, 

including cancer of the lung, bladder, cervix, 

pancreas, kidney, larynx, esophagus, liver, 

and colon. 

• 	Have a higher risk for delayed conception 

and infertility. 

• 	Are more likely to deliver premature and lowbirth-weight infants. 

• 	Have an increased risk for ischemic stroke, 

subarachnoid hemorrhage, peripheral 

vascular atherosclerosis, and an abdominal 

aortic aneurysm rupture. 

• 	Are more likely to have premature decline in 

lung function, chronic obstructive pulmonary 

disease, and coronary heart disease. 

• 	Have an increased risk of developing 

cataracts and macular degeneration. 

• 	 Reach menopause at a younger age. 

• 	Have lower bone densities and an increased 

risk for hip fracture after menopause. 

Effects of Alcohol, Drugs, 

and Tobacco Use on 

Pregnancy and Birth 

Outcomes 

The use of alcohol, drugs, and tobacco can 

affect a pregnant woman in a variety of ways. 

Substance use can result in obstetric complications, miscarriage, or significant problems for 

the fetus. It is difficult to tease out individual 

effects of licit and illicit substances on fetal and 

infant development because women who abuse 

these substances typically abuse more than one, 

and the substance abuse can be accompanied 

by psychological distress, victimization, and 

poverty. A detailed discussion of alcohol- and 

drug-related problems in infants and children is 

beyond the scope of this TIP except insofar as 

these problems create additional demands and 

stressors for women as well as guilt and shame 

about the use of alcohol, drugs, and/or tobacco during pregnancy. This section highlights 

specific effects of alcohol and drugs during the 

course of pregnancy. 

Alcohol Use and Birth Outcomes 

Above all other drugs, alcohol is the most 

common teratogen (any agent that interrupts 

development or causes malformation in an 

embryo or fetus) in pregnancy (Randall 2001). 

48 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
In utero, alcohol use is associated with an 

increased risk of spontaneous abortion and 

increased rates of prematurity and abruptio 

placentae (premature separation of the placenta 

from the uterus). A study found that women who 

consumed five or more drinks per week were 

three times as likely to deliver a stillborn baby 

compared with those who had fewer than one 

drink per week (Kesmodel et al. 2002). 

Maternal alcohol use during pregnancy 

contributes to a wide range of effects on 

exposed offspring, known as fetal alcohol 

spectrum disorders (FASDs), and the most 

serious consequence is fetal alcohol syndrome 

(FAS). FAS is characterized by abnormal facial 

features, growth deficiencies, and central 

nervous system problems (Jones and Smith 

1973). Symptoms can include hyperactivity 

and attention problems, learning and memory 

deficits, and problems with social and emotional 

development. Infants who show only some of 

these features were previously identifi ed as 

having fetal alcohol effects (FAE). Since 1996, 

the term FAE has been replaced by alcoholrelated birth defects (ARBD), partial fetal 

alcohol syndrome (pFAS), and alcohol-related 

neurodevelopmental disorder (ARND; Stratton 

et al. 1996). Children with ARBD have problems 

with major and sensory organs, as well as 

structural abnormalities; children with ARND 

have central nervous system abnormalities 

(Green 2007). Despite alcohol-related birth 

defects being completely preventable, FASDs 

are the most common nonhereditary causes of 

mental retardation (CDC 2002). 

Another risk factor associated with alcohol 

exposure in utero is the potential of substance 

use disorders. Alati et al (2006) found an 

association of early-onset of alcohol disorders 

among children exposed to alcohol prenatally; 

this association was more pronounced with 

early pregnancy exposure. While little is known 

about the prevalence of FASD among individuals 

with substance use disorders, this co-occurring 

condition is likely to further challenge recovery 

effects. For guidelines in identifying and 

referring persons with FAS, see CDC (2005). 

Women who drink during breastfeeding pass 

alcohol on to the baby. Although numerous 

studies of laboratory animals have demonstrated 

a variety of adverse outcomes in breastfed 

offspring during periods when their mothers 

are consuming alcohol, human data are limited. 

A review of empirical literature on women who 

drink while breastfeeding provides evidence that 

maternal alcohol consumption does not promote 

lactation and may affect infant sleep patterns. 

(for review, see Giglia and Binns 2006) 

Cocaine Use and 

Birth Outcomes 

According to reviews 

of several studies 

conducted during the 

late 1980s and early 

1990s, there are a 

variety of adverse effects 

of cocaine use during 

pregnancy (Zuckerman 

et al. 1995; Burkett et al. 

1994). Studies reported 

that cocaine-exposed 

infants had smaller 

head circumference; 

lower birth weight and 

length; irritability; poor 

interactive abilities; and 

an increased incidence of 

stillbirth, prematurity, 

and sudden infant death 

syndrome (SIDS; Bell 

and Lau 1995). Other 

studies dispute many 

previously reported 

severe effects of prenatal 

exposure of cocaine on 

the offspring. Frank and 

colleagues’ review (2001) 

of the literature found 

that the most consistent 

effects were small size 

and less-than-optimal 

The SAMHSA 

FASD’s Center for 

Excellence Web site 

provides information

and resources 

about FASD and 

related information 

on legislation,

treatment and

training curricula,

and community

awareness (http:// 

www.fascenter. 

samhsa.gov/).

motor performance. 

Eyler and colleagues (2001) found no evidence 

of the previously reported devastating effects of 

prenatal cocaine exposure. Hurt and colleagues 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 49 
Advice to Clinicians: 

Substance Use and Birth Outcomes 

• 	 Counselors should be sensitive to female clients who are pregnant and help them 

manage the additional stresses, demands, and guilt that pregnancy can cause in a 

woman already struggling with a substance use disorder. 

• 	 Counselors can take the opportunity to educate their pregnant clients about how 

alcohol, tobacco, and cocaine affect the fetus in a variety of ways that are dose and 

timing dependent, which is an optimistic basis for encouraging pregnant women to 

remain abstinent during pregnancy and while breastfeeding. 

• 	 Pregnant women using opioids should enter methadone maintenance treatment, 

which protects the fetus from repeated episodes of withdrawal, eliminates the risks 

of infection from needles, and creates a mandatory link to prenatal care. 

(1995) followed a cohort of cocaine-exposed 

infants from birth to age 6; although they found 

lower weight and head circumference, they 

found no difference in developmental scores 

between cocaine-exposed and non–cocaineexposed infants. However, other evidence 

suggests that children exposed to cocaine during 

the first trimester were smaller on all growth 

parameters at 7 and 10 years of age compared 

with children who were not exposed to cocaine 

(Richardson et al. 2007). This longitudinal 

analysis indicated that the disparity in growth 

between both groups did not converge over time. 

An extensive review by Frank and colleagues 

(2001) of all studies published in English 

from 1984 to 2000 (N = 74) that met rigorous 

methodological criteria (N = 36) concluded that 

many apparent adverse outcomes of cocaine use 

during pregnancy “can be explained ... by other 

factors, including prenatal exposure to tobacco, 

marijuana, or alcohol and the quality of the 

child’s environment” (p. 1624). Other studies 

(Hurt et al. 2001; Kaltenbach 2000; Lewis et al. 

2004b; Messinger et al. 2004) have supported 

this conclusion. Singer et al. (2004) reported 

that the quality of the caregiving environment 

was the strongest independent predictor of 

cognitive outcomes among children exposed to 

cocaine. 

Nonetheless, the effects of cocaine on the 

fetus may be dose and timing dependent, and 

significant cocaine use during pregnancy, with 

or without other drug use, is associated with 

negative consequences for the offspring and 

the mother (Thaithumyanon et al. 2005). Birth 

weight, length, and head circumference of 

infants with high exposure to cocaine differed 

from those with low or no exposure (Bateman 

and Chiriboga 2000). Heavily cocaine-exposed 

infants were found to have more jitteriness 

and attention problems than infants with light 

or no exposure to cocaine and lower auditory 

comprehension than unexposed infants (Singer 

et al. 2000). Evidence suggests that subtle 

deficits exist in cognitive and attentional 

processes in cocaine-exposed preschool and 

6-year-old children (Leech et al. 1999; Mayes et 

al. 1998). In addition, infants exposed to cocaine 

during pregnancy had more infections, including 

hepatitis and HIV/AIDS exposure (Bauer et 

al. 2005). Much is still unknown about the 

effects of prenatal cocaine exposure. However, 

cocaine use by a pregnant woman should be 

viewed as an indication of multiple medical and 

social risk factors (Eyler and Behnke 1999; 

Tronick and Beeghly 1999); her ability to access 

prenatal care, gain supportive and effective 

case management services, and obtain substance 

abuse treatment can make all the difference in 

outcome. 

Opioid Use and Birth Outcomes 

Opioid use in pregnant women presents a 

difficult situation because of the many medical 

complications of opioid use, such as infections 

passed to the fetus by the use of contaminated 

needles. Obstetric complications in pregnant 

50 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
Note to Clinicians 

Since timely treatment for HIV/AIDS can virtually eliminate the chance of a pregnant woman 

passing the infection to her fetus, all women with substance use histories should have an HIV/ 

AIDS evaluation at the first sign of any possible pregnancy. 

women who use opioids often are compounded 

by lack of prenatal care. Complications 

include spontaneous abortion, premature 

labor and delivery, premature rupture of 

membranes, preeclampsia (high blood pressure 

during pregnancy), abruptio placentae, and 

intrauterine death. The fetus is at risk for 

morbidity and mortality because of episodes of 

maternal withdrawal (Kaltenbach et al. 1998). 

Reviews of several studies recommend 

methadone maintenance treatment (MMT) as 

the only treatment for the management of opioid 

dependence during pregnancy because, when 

methadone is provided within a treatment setting 

that includes comprehensive care, obstetric 

and fetal complications, including neonatal 

morbidity and mortality, can be reduced (Jarvis 

and Schnoll 1995; Kaltenbach et al. 1998). 

Effective MMT prevents the onset of withdrawal, 

reduces or eliminates drug craving, and blocks 

the euphoric effects of illicit self-administered 

opioids (Dole et al. 1966a, b; Kreek 1988). The 

use of methadone in pregnancy prevents erratic 

maternal opioid levels and protects the fetus 

from repeated episodes of withdrawal. Because 

needle use is eliminated, MMT reduces the risk 

of infectious diseases. The mandatory link to 

prenatal care, frequent contact with program 

staff, and elimination of the stress of obtaining 

opioids daily to feel “normal” are additional 

benefits from MMT (Burns et al. 2006). 

Reviews of the literature note that studies 

consistently have found that fetuses exposed 

to opioids (i.e., heroin and methadone) have 

lower birth weights than unexposed fetuses and 

usually undergo neonatal abstinence syndrome 

(NAS) at birth. NAS is a generalized disorder 

characterized by signs and symptoms of central 

nervous system irritability, gastrointestinal 

dysfunction, respiratory distress, vomiting, and 

fever, among other symptoms. NAS can be more 

severe and prolonged with methadone exposure 

than heroin exposure, but with appropriate 

pharmacotherapy, NAS can be treated 

effectively (Kaltenbach 1994; Kaltenbach et al. 

1998). 

Although findings among studies are diverse, 

most suggest that methadone-exposed infants 

and children through age 2 function well within 

the normal range of development and that 

methadone-exposed children between ages 2 

and 5 do not differ in cognitive function from 

a population that was not drug exposed and 

was of comparable socioeconomic and racial 

background (Kaltenbach 1996). Data suggest 

that such psychosocial factors as environment 

and parenting can have as much of an effect on 

development as prenatal exposure to opioids 

(Johnson et al. 1987; Lifschitz et al. 1985). 

In more recent years, buprenorphine treatment 

has been examined as an alternative to 

maintenance therapy for opioid dependence 

during pregnancy. Nonetheless, research is 

limited and only two randomized, doubleblind studies have been conducted comparing 

methadone with buprenorphine (Fischer et al. 

2006; Jones et al. 2005; Kayembe-Kay’s and 

Laclyde 2003; Raburn and Bogenschultz 2004). 

For additional information on maintenance 

therapies during pregnancy, see TIP 43 

Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs (CSAT 

2005a) and TIP 40 Clinical Guidelines for the 

Use of Buprenorphine in the Treatment of 

Opioid Addiction (CSAT 2004a). 

Marijuana Use and Birth 

Outcomes 

The limited research on the effects of prenatal 

exposure to marijuana shows somewhat 

inconsistent results (Bell and Lau 1995). 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 51 
Longitudinal studies by Day and colleagues 

(1992) found marijuana to be associated 

with reduced length at birth, but it did not 

affect weight or head circumference. Hurd 

et al. (2005) found that exposed fetuses had 

significantly reduced body weight and length, 

even when the data were adjusted to account 

for maternal alcohol consumption and smoking. 

Children prenatally exposed to marijuana 

functioned above average on the Bayley Scale 

of Infant Development (BSID) at 9 months, but 

third-trimester marijuana use was associated 

with decreased BSID mental scores. Followup 

assessment of these children at age 10 found that 

prenatal marijuana exposure was associated 

with higher levels of behavior problems 

(Goldschmidt et al. 2000). In a review of existing 

data, Fried and Smith (2001) reported that 

although global IQ is unaffected by prenatal 

marijuana exposure, aspects of executive 

function appear to be negatively associated 

with prenatal exposure in children beyond the 

toddler stage. 

Amphetamine and 

Methamphetamine Use and Birth 

Outcomes 

Exposure to amphetamines in utero has been 

associated with both short- and long-term 

effects, including abnormal fetal growth, 

withdrawal symptoms after birth, and impaired 

neurological development in infancy and 

childhood (Wagner et al. 1998). Both animal and 

human studies have shown that fetal exposure 

to amphetamines increases the risk of reduced 

fetal growth, cardiac anomalies, and cleft lip 

and palate (Winslow et al. 2007). Unfortunately, 

knowledge of the effects of methamphetamine 

during pregnancy is limited. While there is 

evidence of increased rates of premature 

delivery, placental abruption, reduced fetal 

growth, and heart abnormalities, studies 

are confounded by other issues, including 

polysubstance abuse among participants and 

methodological issues in the research design. 

In one study, which took into account several 

confounding variables, fi ndings suggest 

that methamphetamine exposure in utero is 

associated with decreased growth (including 

lower birth weight) and smaller gestational age 

for exposed neonates (Smith et al. 2006). 

Tobacco Use and Birth Outcomes 

Women who smoke tobacco increase their 

chances of ectopic pregnancy (development of a 

fetus outside the uterus), spontaneous abortion, 

premature rupture of membranes, abruptio 

placentae, placenta previa, preeclampsia, 

and preterm delivery. Infants born to women 

who smoke are more likely to have lower birth 

weights and have an increased risk of SIDS 

(Office of the Surgeon General 2001b; Visscher 

et al. 2003). Children of parents who smoke 

heavily can be affected adversely in their 

auditory, language, and cognitive performance; 

hyperactivity and attention defi cit disorders 

are also common, according to the literature 

(Bell and Lau 1995). Studies have also drawn an 

association between maternal smoking during 

pregnancy and disruptive behavior earlier in 

development (NIDA 2008; Wakschlag et al. 

2006; Wakschlag et al. 2002). 

Effects of Alcohol and 

Illicit Drugs on HIV/AIDS 

Status 

People who inject drugs have a high prevalence 

of co-infection with tuberculosis, hepatitis, and 

HIV (Cohn 2002; Martin et al. 2000). Evidence 

suggests that women who inject drugs often 

incur added risk by injecting after men, who 

often procure the drugs and injection equipment 

(Pugatch et al. 2000). According to CDC (2002), 

57 percent of HIV infections among women 

are attributable to use of injection drugs or 

intercourse with a person who injects drugs. 

Some substances make women more vulnerable 

to STDs because of physiological changes. For 

example, women who abuse large amounts of 

alcohol tend to have drier mucous membranes, 

which results in abrasions and small tears that 

allow HIV easier access to the bloodstream 

during intercourse (Norris and Hughes 1996). 

52 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
Douching increases vulnerability to HIV by 

removing protective bacteria (Cottrell 2003; 

Funkhouser et al. 2002). 

Since timely treatment for HIV/AIDS can 

virtually eliminate the chance of a pregnant 

woman passing the infection to her fetus, all 

women with substance use histories should have 

an HIV/AIDS evaluation at the first sign of any 

possible pregnancy. 

Although highly active antiretroviral therapy 

(HAART) has extended survival time, evidence 

suggests that the gains are not equal when 

comparing gender and status as a person who 

uses injection drugs. Poundstone and colleagues 

(2001) concluded that women who inject drugs 

do not benefit as much as men and women 

who do not use injectable drugs. CDC (1998) 

reports that antiretroviral drugs administered to 

pregnant women and their newborns have been 

shown to reduce greatly the risk of perinatal 

mother-to-child HIV/AIDS transmission. 

Aggressive combinations of drugs currently are 

recommended, but the specific regimens that 

can both treat a client’s HIV/AIDS infection 

and reduce perinatal transmission depend on 

many factors. The ability to provide effective 

health care to women who are HIV positive 

can be infl uenced significantly by their use of 

substances and adherence to therapy (Lucas 

et al. 2006). Once women are in treatment, 

counselors need to ensure that they are provided 

with or referred for medical and prenatal 

care as soon as possible to prevent medical 

complications. For more detailed information 

regarding HIV/AIDS, refer to TIP 37 Substance 

Abuse Treatment for Persons with HIV/AIDS 

(CSAT 2000c). 

HCV and Women 

The hepatitis C virus (HCV) is the primary 

cause of cirrhosis and liver cancer in United 

States. An estimated 4.1 million people in the 

United States are infected with HCV. Of these, 

80 to 85 percent will develop chronic hepatitis 

C, but the rate is lower for women. In 2006, 

the rate of HCV in women was 0.25 cases per 

100,000 (CDC 2008). 

HCV can remain silent for many years; most 

people infected with chronic hepatitis C thus 

may not be aware that they are infected because 

they are not chronically ill (Heintges and Wands 

1997). For some, the only sign of an infection is 

found in blood test results. A positive result can 

occur when the liver enzyme ALT is abnormally 

high. Women’s ALT levels are naturally lower 

than men’s, yet the cutoff number for abnormal 

liver tests is the same for both sexes. This can 

result in women being misdiagnosed as having 

a normal ALT level. If a woman’s liver enzymes 

are on the high side of normal or she has any 

risk factors for HCV, testing is recommended for 

HCV (Porter 2008). 

Approximately 250,000 women are infected with 

HCV due to blood they received after a cesarean 

section prior to 1992 (Porter 2008). Since 1992, 

screening and regulations on U.S. blood supplies 

ensure that the recipient is free from risks of 

contracting any blood-borne illness. Currently, 

risk factors for contracting HCV are generally 

the same for men and women, yet women are 

at higher risk of contracting HCV from sexual 

contact with an HCV-positive partner, and 

women are more likely to be initiated into drug 

use or share equipment for injection drugs with 

a sexual partner. Below is a list of risk factors 

for acquiring HCV: 

• 	Injection drug use (56 percent of HCV cases 

in men and women reported in 2006; CDC 

2008). 

• 	 Sexual contact with HCV positive partner 

(0–3 percent for women in monogamous 

heterosexual relationships; the risk increases 

with multiple partners, the presence of a 

sexually transmitted disease, hepatitis B 

virus [HBV], or open sores, cuts, or wounds 

[Porter 2008]; 1–12 percent among female 

prostitutes [The C. Everett Koop Institute 

2008]). 

• 	 Occupational exposure (1.5 percent of HCV 

cases reported in 2006; CDC 2008) through 

the use of razors, needles, nail fi les, a 

barber’s scissors, tattooing equipment, or 

body piercing or acupuncture needles if these 

items are contaminated by blood from an 

infected person. 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 53 
• 	Perinatal or vertical transmission (5 

percent in children of mothers with HCV 

monoinfection; 18.7 percent rate in mothers 

with HIV/HCV co-infection; Bell et al. 2004). 

Almost one out of four newly diagnosed cases 

of HIV in the United States is a woman, and 

approximately 20 percent of these newly 

diagnosed women with HIV are co-infected 

with HCV (Orenstein and Tsogas 2001). Among 

pregnant and nonpregnant women, HCV and 

HIV co-infection is signifi cantly associated 

with injection drug use (Nikolopoulou et al. 

2005). The rate of HIV/HCV co-infection may 

be as high as 50 to 90 percent for those who 

contracted HIV through injection drug use. HIV 

co-infection with HCV appears to raise the risk 

of mother-to-child transmission to 18.7 percent. 

The risk for transmission from a woman with 

HCV monoinfection to her infant is 5.4 percent 

(Bell et al. 2004). 

Prevention and intervention 

Prevention strategies are gender neutral and 

include screening blood, plasma, organ, tissue, 

and sperm donors; effective infection control 

practices; identification, testing, and counseling 

of at-risk persons; and medical management of 

infected persons (Bell 2004). 

Although this is by no means an overview of 

the disease or its treatment process, a review of 

interventions can prove beneficial when working 

with clients who are infected with HCV. Genderspecific guidelines for intervention are minimal. 

Early medical intervention is helpful even 

though people infected with HCV infection often 

experience mild symptoms and subsequently 

do not seek treatment. Not everyone with 

hepatitis C needs medical treatment. Treatment 

is determined by HCV genotype, viral load, liver 

enzyme levels, and extent of liver damage. There 

are many elements to consider when undergoing 

treatment for chronic hepatitis C virus. Women 

are slightly more likely to respond favorably 

to HCV treatment; however, there are genderspecific issues that factor into the decision to 

start treatment. 

Issues of treatment specifi c to 

women 

• 	Women should not get pregnant during and 

up to 6 months following HCV treatment; for 

those who are in treatment after childbirth, 

breastfeeding should be avoided. 

• 	Autoimmune conditions occur more often 

in women than men. One of the HCV 

medications, interferon, can aggravate 

autoimmune diseases. 

• 	Women have less hemoglobin (a component 

of red blood cells that carries oxygen to the 

cells) than men. Menstruating women have 

even lower hemoglobin levels because of 

monthly blood loss, which can sometimes 

cause anemia. HCV-positive women 

undergoing treatment should talk to their 

medical advisor about ribavirin (one of the 

treatment medications for HCV) and its 

connection to hemolytic anemia—a type of 

anemia that causes red blood cells to burst 

before the body has a chance to use them. 

Women, especially menstruating women, are 

vulnerable to this kind of anemia and need to 

be monitored with regular blood tests during 

treatment. 

In general, women are two times more likely 

than men to have depression. Depression 

is a common side effect of HCV treatment 

medications. Some providers recommend 

starting an antidepressant prior to starting 

treatment for HCV (Porter 2005). 

Women are less likely to need HCV treatment 

because they tend to have less severe liver 

damage due to the virus (Highleyman 2005). 

Approximately 3 to 20 percent of clients with 

chronic HCV will develop cirrhosis over a 20- to 

30-year period (CDC 1998). Alcoholic beverage 

consumption accelerates HCV-associated fi brosis 

and cirrhosis. A study by Chen et al. (2007) 

reveals that heavy alcohol use affects females 

more strongly than males, resulting in a higher 

mortality rate. This difference may be due to 

the more detrimental effect of alcohol on the 

progression of liver injury among women than 

among men with a similar level of alcohol use 

(Becker et al. 1996). Current guidelines strongly 

54 Physiological Effects of Alcohol, Drugs, and Tobacco on Women 
recommend that HCV patients be vaccinated 

for hepatitis A and B if they have not yet 

been exposed to these viruses, as these would 

radically worsen their liver disease. 

Some ways addiction counselors can contribute 

to treatment are (for review, see Sylvestre 2007): 

• 	Providing education and lifestyle guidelines. 

• 	 Distributing information on HCV in 

substance abuse treatment programs. 

• 	Providing information on intervention 

programs such as the Healthy Liver Group. 

The Healthy Liver Group, launched in 2005, 

is an hour-long intervention comprising 

a 30-minute group educational session 

followed by an individualized meeting with 

the attending registered nurse to discuss 

laboratory results (Hagedorn et al. 2007). 

• 	Teaching coping skills for side effects to 

clients undergoing medical therapy. 

• 	Promoting self-care by urging clients to 

abstain from alcohol, to get vaccinated for 

hepatitis A and hepatitis B, and to inform 

themselves of HCV and its risk factors. 

• 	Providing moral support and hope to clients 

of obtaining the best possible results by 

maintaining treatment. 

Accessing screening and care on behalf of 

addicted clients with HCV can take persistence. 

Although the HCV antibody screening test is 

relatively inexpensive, the HCV viral test is not, 

but most county medical clinics and hospitals 

will provide it (Sylvestre 2007). Substance abuse 

treatment providers are more apt to spot the 

signs of depression or mania in those patients on 

medical therapy for HCV. Early detection and 

stabilization of any psychiatric side effect should 

not interrupt the progression of treatment. 

People with a substance use disorder can 

participate successfully in HCV therapy. For 

more information, see the planned TIP Viral 

Hepatitis and Substance Use Disorders (CSAT 

in development j). 

Physiological Effects of Alcohol, Drugs, and Tobacco on Women 55 
In This
 

Chapter
 

The Difference 


Between Screening 


and Assessment
 

Screening and 


Assessment: Factors of 


Infl uence
 

Screening
 

Assessment
 

4 Screening and 


Assessment
 

Overview 

Understanding the extent and nature of a woman’s substance use 

disorder and its interaction with other life areas is essential for careful 

diagnosis, appropriate case management, and successful treatment. 

This understanding begins during the screening and assessment process, 

which helps match the client with appropriate treatment services. To 

ensure that important information is obtained, providers should use 

standardized screening and assessment instruments and interview 

protocols, some of which have been studied for their sensitivity, validity, 

and accuracy in identifying problems with women. 

Hundreds of screening instruments and assessment tools exist. Specifi c 

instruments are available to help counselors determine whether further 

assessment is warranted, the nature and extent of a client’s substance 

use disorder, whether a client has a mental disorder, what types of 

traumatic experiences a client has had and what the consequences 

are, and treatment-related factors that impact the client’s response 

to interventions. This TIP makes no specific recommendations of 

screening and assessment tools for women and does not intend to 

present a comprehensive discussion of this complex topic. Rather, the 

TIP briefly describes several instruments that providers often use to 

examine areas of female clients’ lives. Attention is given to instruments 

that have gender-specific normative data or are useful in attending to 

the biopsychosocial issues unique to women. Several of the screening 

and assessment instruments discussed in this chapter are provided in 

Appendix C. 

This chapter introduces and provides an overview of current screening 

and assessment processes that may best serve women across the 

continuum of care. It covers several areas for which to screen, such as 

acute safety risk, mental disorders, sexual victimization, trauma, and 

eating disorders. The chapter also discusses factors that may infl uence 

the overall assessment, and reviews screening for substance abuse and 

dependence in settings other than substance abuse treatment facilities. 

Screening and Assessment 57 
It provides information about instruments for 

use by drug and alcohol counselors, primary 

healthcare providers, social workers, and others. 

The assessment section includes general principles 

for assessing women, the scope and structure of 

assessment interviews, and selected instruments. 

Finally, other considerations that apply to 

screening and assessment are discussed, including 

women’s strengths, coping styles, and spirituality. 

The Difference Between 

Screening and Assessment 

The purpose of screening is to determine 


whether a woman needs assessment. The 


purpose of assessment is to gather the detailed 


information needed for a treatment plan that 


meets the individual needs of the woman. 


Many standardized instruments and interview 


protocols are available to help counselors 


perform appropriate screening and assessment 


for women.
 

Screening involves asking questions carefully 

designed to determine whether a more thorough 

evaluation for a particular problem or disorder is warranted. Many screening instruments 

require little or no special training to administer. 

Screening differs from assessment in the following ways: 

• 	 Screening is a process for evaluating the 

possible presence of a particular problem. 

The outcome is normally a simple yes or no. 

• 	 Assessment is a process for defi ning the 

nature of that problem, determining a 

diagnosis, and developing specifi c treatment 

recommendations for addressing the problem 

or diagnosis. 

Screening and Assessment: 

Factors of Infl uence 

Ethnicity and Culture 

The treatment field depends on tools or 


questionnaires that, for the most part, have 


been found valid and reliable with two 


populations of women—Caucasians and 

African Americans. Although translations of 

some instruments for non–English-speaking 

populations have been made, the validity of the 

adapted instruments is not always documented. 

Women need a thorough explanation of the 

screening and assessment process. Some women 

from diverse ethnic groups may find the process 

threatening, intrusive, and foreign. In some 

cultures, for example, questions about personal 

habits can be considered unnecessarily intrusive 

(Paniagua 1998). Many immigrant women have 

little experience with American medical care 

and do not understand the assessment process. 

Some women may have had negative experiences 

with human service agencies or other treatment 

programs and felt they were stereotyped or 

treated with disrespect. 

Screening and assessment must be approached 

with a perspective that affi rms cultural 

relevance and strengths. An understanding of 

the cultural basis of a client’s health beliefs, 

illness behaviors, and attitude toward and 

acceptance of treatment provides a foundation 

for building a successful treatment program 

for the client. Whenever possible, instruments 

that have been normed, adapted, or tested on 

specific cultural and linguistic groups should 

be used. Instruments that are not normed for 

the population being evaluated can contain 

cultural biases and produce misleading results 

and perhaps inappropriate treatment plans and 

misunderstandings with clients. 

Counselors and intake personnel may hold 

preconceived beliefs concerning the prevalence 

of substance abuse among women from particular ethnic groups. For example, counselors may 

overlook the need to screen and assess Asian 

women (Kitano and Louie 2002). All assessment 

staff members should receive training about 

the cultural and ethnic groups they serve; the 

appropriate interpersonal and communication styles for effective interviews; and cultural 

beliefs and practices about substance use and 

abuse, mental health, physical health, violence, 

and trauma. Through training, counselors can 

learn what cultural factors need to be considered to test accurately. 

58 Screening and Assessment 
Advice to Clinicians and Administrators: 

Culturally Responsive Screening and Assessment 

For Clinicians: 

• 	 Foremost, instruments should be used that have been adapted and tested on women 

in specific cultural groups and special populations. 

• 	 Even though a woman may speak English well, she may have trouble understanding 

the subtleties of questions on standard assessment tools. 

• 	 Acculturation levels can affect screening and assessment results. A single question 

may need to be replaced with an in-depth discussion with the client or family 

members in order to understand substance use from the client’s point of view. 

• 	 Interviews should be conducted in a client’s preferred language by trained staff 

members or an interpreter from the woman’s culture. 

• 	 It is important to remember that many instruments have not been tested on women 

across cultural groups, and that caution should be taken in interpreting the results. 

Counselors need to discuss the limitations of instruments they use with clients 

(Gopaul-McNicol and Brice-Baker 1998). 

For Administrators: 

• 	 Treatment programs can ask community members, professionals, and other treatment 

staff from culturally diverse communities to assist in tailoring assessment instruments 

and protocols for their clients. CSAT’s planned TIP Improving Cultural Competence in 

Substance Abuse Treatment (CSAT in development a) discusses these issues in greater 

detail. 

Acculturation and 

Language Issues 

Acculturation level may affect screening and 

assessment results. The counselor may need 

to replace standard screening and assessment 

approaches with an in-depth discussion with 

the client and perhaps family members to 

understand substance use from the client’s 

personal and cultural points of view. The 

migration experience needs to be assessed; some 

immigrants may have experienced trauma in 

their countries of origin and will need a sensitive 

trauma assessment. 

Specifically, the counselor may begin by asking 

the client about her country of birth and, if she 

was not born in the United States, the length 

of time she has lived in this country. Several 

screening tools are available to determine general acculturation level. The Short Acculturation Scale for Latinos (Marin et al. 1987) is a 

12-item acculturation scale available in English 

and Spanish. Acculturation, as measured by 

this scale, correlates highly with respondents’ 

generation, length of residence, age at arrival, 

and ethnic self-identification. The scale can be 

adapted easily for other groups. Two other useful scales are the Acculturation Rating Scale for 

Mexican Americans II (ARSMA; Cuéllar et al. 

1980) and the Oetting and Beauvais Questionnaire, available at www.casaa.unm.edu, which 

assesses cultural identification for Caucasian 

Americans, Hispanics, American Indians, and 

African Americans. Scales also have been developed for Asian-American groups (Chung et al. 

2004). 

Counselors should be aware that although a client speaks English relatively well, she still may 

have trouble understanding assessment tools in 

English. It is not adequate to simply translate 

items from English into another language. Some 

Screening and Assessment 59 
words, idioms, and examples do not translate 

directly into other languages but need to be 

adapted. Ideally, interviews should be conducted in a woman’s preferred language by trained 

staff who speak the language or by professional 

translators from the woman’s culture. Differences in literacy level may require that some 

clients be screened and assessed by interview or 

that self-administered questions be adapted to 

appropriate reading levels. For women with low 

literacy levels, language comprehension problems, or visual impairments, screening personnel can read the questions to them; however, results may not be as accurate. Self-administered 

questionnaires should be available in a woman’s 

preferred language if possible. 

Socioeconomic Status 

Counselors may have conscious or subconscious 

expectations based on socioeconomic status. 

Such perceptions have led to failures to diagnose 

drug or alcohol abuse in pregnant middle- and 

upper-class women, with tragic consequences 

for their infants. For example, primary care 

providers are much less apt to ask private 

middle-income patients about their use of 

drugs. Some healthcare providers may fear 

offending their patients by asking them about 

their substance use. Weir and colleagues (1998) 

found that clients with more than a high school 

education are less apt to disclose the use of 

drugs or alcohol during pregnancy. 

Specific Populations: Other 

Noteworthy Considerations 

Cognitive and learning disabilities 

Prior to screening and assessment, the counselor 

should inquire about current or past diffi culties 

in learning, past participation in special 

education, a diagnosis of a learning disability, 

prior involvement in testing for cognitive 

functioning or learning disability, and problems 

related to self-care and basic life management 

skills. 

Depending on the type and severity of the 

disability or impairment, these women will likely 

need more assistance throughout the screening 

and assessment process. Moreover, women 

with developmental disabilities or cognitive 

impairments are more likely to respond to 

items they do not understand by stating “yes” 

or by responding in a manner they think the 

assessment counselor will approve of instead of 

asking for clarifi cation. 

Sexual orientation 

The Institute of Medicine’s (IOM) report on 

lesbian health identifies substance abuse as one 

of the primary heath concerns among lesbians 

(Solarz 1999). While research has concluded 

that the CAGE instrument has similar reliability 

and concurrent validity among lesbian and 

heterosexual women, very few studies have 

addressed the issue of validity and reliability 

in screening and assessment tools for lesbians 

(Johnson and Hughes 2005). Consequently, 

counselors need to cautiously interpret 

screening and assessment results. 

Screening 

Screening often is the initial contact between a 

woman and the treatment system, and the client 

forms her first impression of treatment during 

screening and intake. For women, the most 

frequent points of entry from other systems of 

care are obstetric and primary care; hospital 

emergency rooms; social service agencies in 

connection with housing, child care, disabilities, 

and domestic violence; community mental 

health services; and correctional facilities. How 

screening is conducted can be as important as 

the actual information gathered, as it sets the 

tone of treatment and begins the relationship 

with the client. 

Screening processes always should defi ne a 

protocol or procedure for determining which 

clients need further assessment (i.e., screen 

positive) for a condition being screened and for 

ensuring that those clients receive a thorough 

assessment. That is, a professionally designed 

screening process establishes precisely how 

to score responses to the screening tools or 

questions and what constitutes a positive score 

for a particular possible problem (often called 

60 Screening and Assessment 
Advice to Clinicians: 

Substance Abuse Screening and Assessment Among Women 

• How screenings and assessments are conducted is as important as the information

gathered. Screening and assessment are often the initial contact between a woman 

and the treatment system. They can either help build a trusting relationship or create 

a deterrent to engaging in further services. 

• Self-administered tools may be more likely to elicit honest answers; this is especially

true regarding questions related to drug and alcohol use. 

• Face-to-face screening interviews have not always been successful in detecting

alcohol and drug use in women, especially if the counselor is uncomfortable with the 

questions. 

• Substance abuse screening and assessment tools, in general, are not as sensitive in

identifying women as having substance abuse problems. 

• Selection of screening and assessment instruments should be examined to determine

if they were developed using female populations. If not, counselors need to explore 

whether or not there are other instruments that may be more suitable to address 

specific evaluation needs. 

a “cutoff” score). The screening protocol details 

the actions taken after a client scores in the 

positive range and provides the standard forms 

for documenting the results of the screening, 

the actions taken, the assessments performed, 

and that each staff member has carried out his 

or her responsibilities in the process. Although 

a screening can reveal an outline of a client’s 

involvement with alcohol, drugs, or both, it 

does not result in a diagnosis or provide details 

of how substances have affected the client’s life. 

The most important domains to screen for when 

working with women include: 

• 	 Substance abuse 

• 	 Pregnancy considerations 

• 	 Immediate risks related to serious 

intoxication or withdrawal 

• 	 Immediate risks for self-harm, suicide, and 

violence 

• 	 Past and present mental disorders, including 

posttraumatic stress disorder (PTSD) and 

other anxiety disorders, mood disorders, 

and eating disorders 

• 	 Past and present history of violence and 

trauma, including sexual victimization and 

interpersonal violence 

• 	 Health screenings, including HIV/AIDS, 

hepatitis, tuberculosis, and STDs 

Substance 

Abuse Screening 

The goal of substance 

abuse screening is to 

identify women who 

have or are developing 

alcohol- or drugrelated problems. 

Routinely, women are 

less likely than men 

to be identifi ed as 

having substance abuse 

problems (Buchsbaum 

et al. 1993); yet, they 

are more likely to 

exhibit signifi cant 

health problems after 

consuming fewer 

substances in a shorter 

Substance abuse 


screening and 


assessment tools, 


in general, are 


not as sensitive in 


identifying women 


as having substance 


abuse problems.
 

period of time. 

Screening for substance use disorders is 

conducted by an interview or by giving a 

short written questionnaire. While selection 

of the instrument may be based on various 

factors, including cost and administration time 

(Thornberry et al. 2002), the decision to use an 

interview versus a self-administered screening 

tool should also be based upon the comfort level 

of the counselor or healthcare professional 

(Arborelius and Thakker 1995; Duszynski et al. 

Screening and Assessment 61 
1995; Gale et al. 1998; Thornberry et al. 2002). 

If the healthcare staff communicates discomfort, 

women may become wary of disclosing their full 

use of substances (Aquilino 1994; see also Center 

for Substance Abuse Prevention [CSAP] 1993). 

Many instruments have been developed to 

screen for alcohol consumption, and several 

measures have been adapted to screen for 

specific drugs. While numerous screening tools 

are available, information about the reliability 

and validity of these instruments with women 

is limited. The following listing, while not 

exhaustive, individually reviews tools with 

available gender-specifi c information. 

General Alcohol and Drug 

Screening 

AUDIT 

The Alcohol Use Disorder Identifi cation Test 

(AUDIT; Babor and Grant 1989) is a widely 

used screening tool that is reproduced with 

guidelines and scoring instructions in TIP 26 

Substance Abuse Among Older Adults (CSAT 

1998d). The AUDIT is effective in identifying 

heavy drinking among nonpregnant women 

(Bradley et al. 1998c). It consists of 10 questions 

that were highly correlated with hazardous or 

harmful alcohol consumption. This instrument 

can be given as a self-administered test, or the 

questions can be read aloud. The AUDIT takes 

about 2 minutes to administer. Note: Question 

3, concerning binge drinking, should be revised 

for women to refer to having 4 (not 6) or more 

drinks on one occasion. 

TCUDS II 

The Texas Christian University Drug Screen 

II (TCUDS II) is a 15-item, self-administered 

substance abuse screening tool that requires 

5–10 minutes to complete. It is based in part 

on Diagnostic Interview Schedule and refers to 

Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition, Text Revision (DSMIV-TR; American Psychiatric Association 

[APA] 2000a) criteria for substance abuse 

and dependence. TCUDS II is used widely in 

criminal justice settings. It has good reliability 

among female populations (Knight 2002; Knight 

et al. 2002). This screen, along with related 

instruments, is available at www.ibr.tcu.edu. 

CAGE 

CAGE (Ewing 1984) asks about lifetime alcohol 


or drug consumption (see Figure 4-1). Each 


“yes” response receives 1 point, and the cutoff 

point (the score that makes the test results 

positive) is either 1 or 2. Two “yes” answers 

results in a very small false-positive rate and 

the clinician will be less likely to identify clients 

as potentially having a substance use disorder 

when they do not. However, the higher cutoff of 

2 points decreases the sensitivity of CAGE for 

women—that is, increases the likelihood that 

some women who are at risk for a substance 

problem will receive a negative screening score 

(i.e., it increases the false-negative rate). Note: 

It is recommended that a cutoff score of 1 be 

employed in screening for women. This measure 

has also been translated and tested for Hispanic/ 

Latina populations. 

Figure 4-1 

The CAGE Questionnaire 

• Have you ever felt you ought to Cut down on your drinking [or drug use]? 

• Have people Annoyed you by criticizing your drinking [or drug use]? 

• Have you ever felt bad or Guilty about your drinking [or drug use]? 

• 	 Have you ever had a drink [or used drugs] first thing in the morning ( Eye opener) to steady 

your nerves or get rid of a hangover [or get the day started]? 

Source: Mayfield et al. 1974.
 

62 Screening and Assessment 
A common criticism of the CAGE is that it is 

not gender-sensitive—that is, women who have 

problems associated with alcohol use are less 

likely than male counterparts to screen positive 

when this instrument is used. One study of more 

than 1,000 women found that asking simple 

questions about frequency and quantity of 

drinking, coupled with a question about binge 

drinking, was better than the CAGE in detecting 

alcohol problems among women (Waterson and 

Murray-Lyon 1988). 

The CAGE is “relatively insensitive” with 

Caucasian females, yet Bradley and colleagues 

report that it “has performed adequately in 

predominantly black populations of women” 

(1998c, p. 170). Johnson and Hughes (2005) 

conclude that CAGE has similar reliability and 

concurrent validity among women of different 

sexual orientations. The CAGE-AID (CAGE 

Adapted to Include Drugs) modifies the CAGE 

questions for use in screening for drugs other 

than alcohol. This version of the CAGE shows 

promise in identifying pregnant, low-income 

women at risk for heavier drug use (Midanik et 

al. 1998). 

Screening for Tobacco Use 

Similar to other substances, women pay an 

exceptional price for using tobacco. The second 

leading cause of death in women is cancer 

(CDC 2004), with tobacco accounting for 90 

percent of all lung cancers, according to the 

Surgeon General’s Report on Women and 

Smoking (2001). Yet, women are less likely to 

be referred to smoking cessation programs or 

provided smoking cessation products (Steinberg 

et al. 2006). Therefore, screening for tobacco 

use and referral for nicotine cessation should 

be standard practice in substance abuse 

treatment. Counselors can simply screen for 

tobacco use beginning with current and past 

patterns of use, including type of tobacco, 

number of cigarettes smoked per day, frequency 

of use, circumstances surrounding use, and 

specific times and locations. For individuals 

who currently smoke, a more comprehensive 

assessment needs to be completed with 

recommendations incorporated into the 

woman’s treatment plan. 

Women who smoked 

in the month before 

pregnancy are nine

times more likely to

be currently using

either drugs or

alcohol or both while 

pregnant (Chasnoff 

et al. 2001). 

Screening 

Instruments for 

Pregnant Women 

Considering the 

devastating impact 

of substances on the 

developing fetus, routine 

screening for drug, 

alcohol, and tobacco use 

among pregnant women 

is imperative. Face-toface screening interviews 

are not always 

successful in detecting 

alcohol and drug use, 

especially in pregnant 

women. However, selfadministered screening 

tools have been found to 

be more likely to elicit 

honest answers (Lessler and O’Reilly 1997; 

Russell et al. 1996; Tourangeau and Smith 

1996). Three screening instruments for use with 

pregnant women are TWEAK, T-ACE, and 5Ps 

Plus (CSAP 1993; Morse et al. 1997). 

TWEAK 

TWEAK (Russell et al. 1991) identifi es pregnant 

women who are at risk for alcohol use (Figure 

4-2). It consists of five items and uses a 7-point 

scoring system. Two points are given for positive 

responses to either of the first two questions 

(tolerance and worry), and positive responses 

to the other three questions score 1 point. A 

cutoff score of 2 indicates the likelihood of risk 

drinking. In a study of more than 3,000 women 

at a prenatal clinic, the TWEAK was found to 

be more sensitive than the CAGE and Michigan 

Alcohol Screening Test (MAST), and more 

specific than the T-ACE (Russell et al. 1996). 

The tolerance question scores 2 points for an 

answer of three or more drinks. However, if the 

criterion for the tolerance question is reduced to 

two drinks for women, the sensitivity of TWEAK 

increases, and the specificity and predictive 

ability decrease somewhat (Chang et al. 1999). 

In comparison with T-ACE, TWEAK had higher 

sensitivity and slightly lower specifi city (Russell 

Screening and Assessment 63 
Figure 4-2 

The TWEAK Questionnaire: Women 

How many drinks does it take for you to feel high? [Tolerance] (2 or more drinks = 2 points) 

Does your partner (or do your parents) ever Worry or complain about your drinking? (yes = 2 


points)
 

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a 


hangover? (Eye opener) (yes = 1 point)
 

Have you ever Awakened the morning after some drinking the night before and found that you 


could not remember part of the evening? (yes = 1 point)
 

Have you ever felt that you ought to K/cut down on your drinking? (yes = 1 point) 

Source: Morse et al. 1997. 

et al. 1994, 1996). It can also be used to screen 5 points. A total of 2 or more points indicates 

for harmful drinking in the general population risk drinking (Chang et al. 1999). T-ACE has 

(Chan et al. 1993). sensitivity equal to the longer MAST and greater 

than CAGE (Bradley et al. 1998c). It has been 

validated only for screening pregnant women T-ACE 

with risky drinking (Russell et al. 1994). The T-ACE is a 4-item instrument appropriate 

for detecting heavy alcohol use in pregnant In a study with a culturally diverse population 

women (Sokol et al. 1989). T-ACE uses the A, C, of pregnant women, Chang and colleagues 

and E questions from CAGE and adds one on (1998) compared T-ACE with the MAST (short 

tolerance for alcohol (see Figure 4-3). The fi rst version) and the AUDIT. The study found 

question assesses tolerance by asking if it takes T-ACE to be the most sensitive of the three tools 

more than it used to to get high. A response of in identifying current alcohol consumption, 

two or more drinks is scored as 2 points, and risky drinking, or lifetime alcohol diagnoses 

the remaining questions are assigned 1 point (Chang et al. 1998). Although T-ACE had the 

for a “yes” response. Scores range from 0 to lowest specificity of the three tests, it is argued 

Figure 4-3 

The T-ACE Questionnaire 

How many drinks does it take you to feel high? [Tolerance] (2 or more drinks = 2 points) 

Have people Annoyed you by criticizing your drinking? (yes = 1 point) 

Have you ever felt you ought to Cut down on you drinking? (yes = 1 point) 

Have you had an Eye opener (a drink first thing in the morning) to steady your nerves? (yes = 1 


point)
 

Source: Sokol et al. 1989 

64 Screening and Assessment 
that false positives are of less concern than false 

negatives among pregnant women (Chang et al. 

1998). 

Prenatal substance abuse screen 

(5Ps) 

This screening approach has been used to 

identify women who are at risk for substance 

abuse in prenatal health settings. A “yes” 

response to any item indicates that the woman 

should be referred for assessment (Morse et 

al. 1997). Originally, four questions regarding 

present and past use, partner with problem, 

and parent history of alcohol or drug problems 

were used (Ewing 1990). However, several 

adaptations have been made, and recently a 

question about tobacco use in the month before 

the client knew she was pregnant was added 

(Chasnoff 2001). Chasnoff and colleagues (2001) 

reported that women who smoked in the month 

before pregnancy were 11 times more likely to 

be currently using drugs and 9 times more likely 

to be currently using either drugs or alcohol or 

both while pregnant. This version, the 5Ps, is 

shown in Figure 4-4. 

In a study evaluating prevalence of substance 

use among pregnant women utilizing this 

screening tool, the authors suggest that it not 

only identified pregnant women with high levels 

of alcohol and drug use but also a larger group 

of women whose pregnancies were at risk from 

smaller amounts of substance use (Chasnoff 

et al. 2005). For a review on how to improve 

screening for pregnant women and motivate 

healthcare professions to screen for risk, refer 

to the Alcohol Use During Pregnancy Project 

(Kennedy et al. 2004). 

Acute Safety Risk Related 

to Serious Intoxication or 

Withdrawal 

Screening for safety related to intoxication and 

withdrawal at intake involves questioning the 

woman and her family or friends (with client’s 

permission) about current substance use or 

recent discontinuation of use, along with past 

and present experiences of withdrawal. If a 

woman is obviously severely intoxicated, she 

needs to be treated with empathy and fi rmness, 

and provision needs to be made for her physical 

safety. If a client has symptoms of withdrawal, 

formal withdrawal scales can be used by trained 

personnel to gather information to determine 

whether medical intervention is required. Such 

tools include the Clinical Institute Withdrawal 

Assessment for Alcohol Withdrawal (Sullivan 

et al. 1989; See Appendix C for specifi c 

Figure 4-4 

5Ps Screening 

Peers: Do any of your friends have a problem with drug or alcohol use?
 

Partner: Does your partner have a problem with alcohol or drugs?
 

Parents: Did either of your parents ever have a problem with alcohol or drugs?
 

Past Use: Before you knew you were pregnant, how often did you drink beer, wine, wine coolers, 


or liquor? Not at all, rarely, sometimes, or frequently?
 

Present Use: In the past month, how often did you drink beer, wine, wine coolers, or liquor? Not 


at all, rarely, sometimes, or frequently?
 

Smoke: How many cigarettes did you smoke in the month prior to pregnancy? 

Source: Morse et al. 1997; Chasnoff et al. 2001 

Screening and Assessment 65 
Advice to Clinicians: 

At-Risk Screening for Drug and Alcohol Use During Pregnancy 

• 

• 

• 

• 

In screening women who are pregnant, face-to-face screening interviews have not 

always been successful in detecting alcohol and drug use. 

Self-administered tools may be more likely to elicit honest answers; this is especially 

true regarding questions related to drug and alcohol use during pregnancy. 

While questions regarding past alcohol and drug use or problems associated with 

self, partner, and parents will help to identify pregnant women who need further 

assessment, counselors should not underestimate the importance of inquiring about 

previous nicotine use in order to identify women who are at risk for substance abuse 

during pregnancy. 

There are other factors that are associated with at-risk substance abuse among 

women who are pregnant, including moderate to severe depression, living alone or 

with young children, and living with someone who uses alcohol or drugs (for review, 

see Chasnoff et al. 2001). 

information) and the Clinical Institute Narcotic 

Assessment for Opioid Withdrawal (Zilm and 

Sellers 1978). While specific normative data 

are unavailable, it is important to screen for 

withdrawal to assess risk and to implement 

appropriate medical and clinical interventions. 

Not all drugs produce physiological withdrawal; 

counselors should not assume that withdrawal 

from any drug of abuse requires medical 

intervention. Only in the case of opioids, 

sedative-hypnotics, or benzodiazepines (and in 

some cases of alcohol), is medical intervention 

likely to be required. Nonetheless, specifi c 

populations may warrant further assessment 

and assistance in detoxifi cation, including 

pregnant women, women of color, women with 

disabilities or co-occurring disorders, and older 

women. (Review TIP 45 Detoxifi cation and 

Substance Abuse Treatment, [CSAT 2006a], pp. 

105–113.) Specific to women who are pregnant 

and dependent on opioids, withdrawal during 

pregnancy poses specific medical risks including 

premature labor and mortality to the fetus. 

Note: Women who are dependent on opioids 

may misinterpret early signs of pregnancy as 

opioid withdrawal symptoms (review TIP 43 

Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs [CSAT 

2005a], pp. 211–224). 

Mental Illness Symptoms and 

Mental Disorders 

Considering that women are twice as likely as 

men to experience mood disorders, excluding 

bipolar and anxiety disorders (Burt and Stein 

2002), all women entering substance abuse 

treatment should be screened for co-occurring 

mental disorders. If the screening indicates the 

possible presence of a disorder, a woman should 

be referred for a comprehensive mental health 

assessment and receive treatment for the cooccurring disorder, as warranted. Depression, 

anxiety, eating disorders, and PTSD are 

common among women who abuse substances 

(McCrady and Raytek 1993). 

Because certain drugs as well as withdrawal 

symptoms can mimic symptoms of mental 

disorders, the continual reassessment of mental 

illness symptoms is essential to ensure accurate 

diagnosis and treatment planning. TIP 42 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005e) contains 

information on screening and treatment of 

persons with co-occurring substance use and 

mental disorders. 

66 Screening and Assessment 
General mental disorder screening 

instruments 

Symptom screening involves questions about 

past or present mental disorder symptoms that 

may indicate the need for a full mental health 

assessment. Circumstances surrounding the 

resolution of symptoms should be explored. For 

example, if the client is taking psychotropic 

medication and is no longer symptomatic, this 

may be an indication that the medication 

is effective and should be continued. Often, 

symptom checklists are used when the counselor 

needs information about how the client is 

feeling. They are not used to screen for specifi c 

disorders, and responses are expected to change 

from one administration to the next. Symptom 

screening should be performed routinely and 

facilitated by the use of formal screening tools. 

Basic mental health screening tools are available 

to assist the substance abuse treatment team. 

The 18 questions in the Mental Health Screening 

Form-III (MHSF-III) screen for present or past 

symptoms of most mental disorders (Carroll 

and McGinley 2001). It is available at no charge 

from the Project Return Foundation, Inc., 

and is reproduced in TIP 42 Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders (CSAT 2005e), along with instructions 

and contact information (a Spanish-language 

form and instructions can be downloaded from 

www.asapnys.org/resources.html). MHSF-III 

was developed in a substance abuse treatment 

setting and is referred to as a “rough screening 

device” (Carroll and McGinley 2001, p. 35). 

The Mini-International Neuropsychiatric 

Interview (M.I.N.I.) is a brief, structured 

interview for more than 20 major psychiatric 

and substance use disorders (Sheehan et al. 

2002). Administration time is 15–30 minutes. 

Scoring is simple and immediate. M.I.N.I. can 

be administered by clinicians after brief training 

and by lay personnel with more extensive 

training. M.I.N.I. can be downloaded from www. 

medical-outcomes.com and used for no cost in 

nonprofit or publicly owned settings. 

The Brief Symptom Inventory is a research 

tool that can be adapted for use as a screening 

checklist. This tool’s 53 items measure 9 

primary symptom 

dimensions as well as 3 

global indices of distress. 

Respondents rate the 

severity of symptoms on 

a 5-point scale ranging 

from “Not at all” (0 

points) to “Extremely” 

(4 points) (Derogatis and 

Melisaratos 1983). 

Depression and 

anxiety disorders 

Many formal tools 

screen for depression, 

including the Beck 

Depression InventoryII (Beck et al. 1996a, 

b; Smith and Erford 

2001; Steer et al. 

1989), the Center 

for Epidemiologic 

Study Depression 

Scale (Radloff 1977), and the General Health 

Questionnaire—a self-administered screening 

test to identify short-term changes in mental 

health (depression, anxiety, social dysfunction, 

and somatic symptoms)—are available. 

Programs that screen for depression should 

ensure that “yes” answers to these questions 

are followed by a comprehensive assessment, 

accurate diagnosis, effective treatment, and 

careful followup. Asking these two questions 

may be as effective as using longer instruments 

(U.S. Preventive Services Task Force 2002). 

Little evidence exists to recommend one 

screening method over another, so clinicians 

can choose the method that best fi ts their 

preference, the specific population of women, 

and the setting. Refer to TIP 48 Managing 

Depressive Symptoms in Substance Abuse 

Clients During Early Recovery (CSAT 2008) 

for more guidance in working with clients who 

have depressive symptoms. Note: Women who 

are depressed are more likely to report bodily 

symptoms, including fatigue, appetite and sleep 

disturbance, and anxiety (Barsky et al. 2001; 

Kornstein et al. 2000; Silverstein 2002). 

The U.S. Preventive 

Services Task Force 

(2002) recommends 

two simple questions 

that are effective in 

screening adults for 

depression: 

1. 	 Over the past 2 

weeks have you felt 

down, depressed, 

or hopeless? 

2. 	 Over the past 2 

weeks have you felt 

little interest or 

pleasure in doing 

things? 

Screening and Assessment 67 
An example of an instrument that can detect 

symptoms of anxiety is the 21-item Beck Anxiety 

Inventory (BAI; Beck 1993; Hewitt and Norton 

1993). Among a group of psychiatric patients 

with a variety of diagnoses, women’s BAI scores 

indicated higher levels of anxiety than men’s 

BAI scores. However, the nature of the anxiety 

reported appears similar for women and men 

(Hewitt and Norton 1993). 

Assessing Risk of Harm to Self or 

Others 

Suicidal attempts and parasuicidal behavior 

(nonfatal self-injurious behavior with clear 

intent to cause bodily harm or death; Welch 

2001) are more prevalent among women. The 

greatest predictor of eventual suicide is prior 

suicidal attempts and deliberate self-harm 

inflicted with no intent to die (Joe et al. 2006). 

While substance dependence and PTSD are 

associated with self-harm and suicidal behavior 

(Harned et al. 2006), the most frequent 

diagnoses associated with suicide are mood 

disorders, specifically depressive episodes 

(Kessler et al. 1999). Considering the prevalence 

of suicidal attempts, self-injurious behavior, 

and depression among women, employing safety 

screenings should be a standard practice. From 

the outset, clinicians should specifi cally ask 

the client and anyone else who is providing 

information whether she is in immediate danger 

and whether she has any immediate intention 

to engage in violent or self-injurious behavior. 

If the answer is “yes,” the clinician should 

obtain more information about the nature and 

severity of the thoughts, plan, and intent, and 

then arrange for an in-depth risk assessment 

by a trained mental health clinician. The client 

should not be left alone. 

No tool is definitive for safety screening. 

Clinicians should use safety screening 

tools only as an initial guide and proceed 

to detailed questions to obtain relevant 

information. In addition, care is needed to 

avoid underestimating risk because a woman is 

using substances or has frequently engaged in 

self-injurious behavior. For example, a woman 

who is intoxicated might seem to be making 

empty threats of self-harm, but all statements 

about harming herself or others must be taken 

seriously. Overall, individuals who have suicidal 

or aggressive impulses when intoxicated are 

more likely to act on those impulses; therefore, 

determination of the seriousness of threats 

requires a skilled mental health assessment, plus 

information from others who know the client 

very well. Screening tools and procedures in 

evaluating risk are discussed in depth in TIP 50 

Addressing Suicidal Thoughts and Behaviors in 

Substance Abuse Treatment (CSAT 2009a). 

Substance abuse treatment programs need 

clear mental health referral and follow-up 

procedures so that clients receive appropriate 

psychiatric evaluations and mental health 

care. The American Association of Community 

Psychiatrists (AACP) developed the Level of 

Care Utilization System for Psychiatric and 

Addiction Services (LOCUS) that evaluates 

clients along six dimensions and defines six levels 

of resource intensity. It includes an excellent 

tool for helping the counselor determine the 

risk of harm (AACP 2000; See Appendix C 

for specific information on the LOCUS). The 

potential risk of harm most frequently takes 

the form of suicidal intentions, and less often 

the form of homicidal intentions. The scale has 

five categories, from minimal risk of harm to 

extreme risk of harm. It is available at www. 

comm.psych.pitt.edu/fi nds/LOCUS2000.pdf 

and can be easily adapted for use in treatment 

facilities. 

Trauma and Posttraumatic Stress 

Disorder 

PTSD can follow a traumatic episode that 

involves witnessing, being threatened, or 

experiencing an actual event involving death or 

serious physical harm, such as auto accidents, 

natural disasters, sexual or physical assault, 

war, and childhood sexual and physical 

abuse (APA 2000a). During the trauma, the 

individual experiences intense fear, helplessness, 

or horror. PTSD has symptoms that last 

longer than 1 month and result in a decline in 

68 Screening and Assessment 
functioning in several life areas, such as work 

and relationships. A diagnosis of PTSD cannot 

be made without a clear history of a traumatic 

event (Figure 4-5 presents sample screening 

questions for identifying a woman’s history of 

trauma). General symptoms of PTSD include 

persistently re-experiencing the traumatic event, 

numbness or avoidance of cues associated with 

the trauma, and a pattern of increased arousal 

(APA 2000a). 

Historically, women have not been routinely 

screened for a history of trauma or assessed 

to determine a diagnosis of PTSD across 

treatment settings (Najavits 2004). Among 

women in substance abuse treatment, it has 

been estimated that 55–99 percent have 

experienced trauma—commonly childhood 

physical or sexual abuse, domestic violence, or 

rape (Najavits et al. 1997; Triffl eman 2003). 

Studies have reported that current PTSD rates 

among women who abuse substances range 

between 14 to 60 percent (Brady 2001; Najavits 

et al. 1998; Triffleman 2003). In comparison to 

men, women who use substances are still more 

than twice as likely to have PTSD (Najavits 

et al. 1997). Brief screening is paramount in 

not only establishing past or present traumatic 

events but in identifying PTSD symptoms. Upon 

identification of traumatic stress symptoms, 

counselors need to refer the women for a mental 

health evaluation in order to further assess 

the presenting symptoms, to determine the 

appropriateness of a PTSD diagnosis, and to 

assist in establishing an appropriate treatment 

plan and approach. Brief screenings are used 

to identify clients who are more likely to have 

Figure 4-5 

Questions to Screen for Trauma History 

Responses include yes, no, or maybe. Maybe is used if the client is unsure (e.g., she was too young 

to remember but suspects it happened). If answering these questions is upsetting, the counselor 

may need to stop the interview or redirect the questions, provide support and reassurance to the 

client, and seek consultation from a clinical supervisor. 

In your lifetime, have you suffered any of the following experiences or seen them happen to 

someone else? (Answers are yes, no, or maybe.) 

• Child physical abuse (e.g., hitting that caused bruises or injury)

• Child sexual abuse (e.g., being molested, touched, or forced into any sexual activity)

• Child neglect (e.g., not enough to eat, inadequate shelter)

• Domestic violence (e.g., a partner who hurt you physically)

• Crime victimization (e.g., rape, holdup)

• Serious accident (e.g., car crash, chemical spill, or fi re) 

• Life-threatening illness (e.g., cancer)

• Natural disaster (e.g., hurricane, earthquake)

• War 

• Captivity or kidnapping

The• threat of any of the events listed above, even if it wasn’t completed (e.g., threat of being 

raped or murdered) 

• Violence by you (e.g., you physically hurt someone, such as abusing a child, murdering 

someone, or attacking someone with a weapon) 

• Other upsetting events (make a list)

Source: Najavits 2002a. 

Screening and Assessment 69 
were not normal and were abusive. Some women 

do not remember the abuse. Therefore, a 

negative finding on abuse at an intake screening 

should not be taken as a final answer. The 

Substance Abuse and Mental Health Services 

Administration (SAMHSA)-funded Women, 

Co-Occurring Disorders and Violence Study 

includes questions about sexual abuse in its 

baseline interview protocol, presented in 

Figure 4-6. In addition, SAMHSA’s CSAT has 

developed a brochure for women that defi nes 

childhood abuse and informs the reader of how 

to begin to address childhood abuse issues while 

in treatment (CSAT 2003a). TIP 36 Substance 

Abuse Treatment for Persons With Child Abuse 

and Neglect Issues (CSAT 2000b) includes 

detailed information on this topic. 

Interpersonal violence 

Studies estimate that between 50 to 99 percent 

of women with substance use disorders have a 

history of interpersonal violence (Miller et al. 

1993; Rice et al. 2001). In one study focused on 

sensitivity and specificity of screening questions 

for intimate partner violence, Paranjape 

and Liebschutz (2003) concluded that when 

three simple screening questions were used 

together, identification of lifetime interpersonal 

violence was effectively identified for women. 

This screening tool, referred as the STaT, is 

presented in Figure 4-7 (p. 72). Along with a 

sample personalized safety plan, additional 

screening tools, including the Abuse Assessment 

Screen (English and Spanish version), Danger 

Assessment, The Psychological Maltreatment 

of Women Inventory, and The Revised Confl ict 

Tactics Scale (CTS2), are available in TIP 25 

Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b). Note: It is important to 

assess for interpersonal violence in heterosexual 

Figure 4-6 

Questions Regarding Sexual Abuse 

Have you ever been bothered or harassed by sexual remarks, jokes, inappropriate touching, or 

demands for sexual favors by someone at work or school? 

• How often has this happened? 

• How old were you when this fi rst happened? 

• Has this happened in the past 6 months? 

Were you ever touched or have you ever touched someone else in a sexual way because you felt 

forced or coerced or threatened by harm to yourself or someone else? 

• How old were you when this fi rst happened? 

• How often did this happen before age 18? 

• How often has this happened since you turned 18? 

• Has this happened in the past 6 months?
 

Did you ever have sex because you felt forced or threatened by harm to yourself or someone else?
 

• How old were you when this fi rst happened? 

• How often did this happen before age 18? 

• How often has this happened since you turned 18? 

• Has this happened in the past 6 months? 

Have you ever had sex when you did not want to in exchange for money, drugs, or other material 

goods such as shelter or clothing? 

• How often has this happened? 

• How old were you when this fi rst happened? 

• Has this happened in the past 6 months? 

Source: SAMHSA n.d. 

Screening and Assessment 71 
Be aware that 

weight gain during

recovery can be a

major concern and 

a relapse risk factor

for women. 

Figure 4-7 

STaT: Intimate Partner Violence Screening Tool 

1. Have you ever been in a relationship where your partner has pushed or Slapped you? 

2. Have you ever been in a relationship where your partner Threatened you with violence? 

3. Have you ever been in a relationship where your partner has thrown, broken, or punched 

Things?
 

Source: Paranjape and Liebschutz 2003. 


and homosexual relationships. 

Interpersonal violence and 


disabilities
 

Women with disabilities are at a signifi cantly 

greater risk for severe interpersonal violence 

and neglect (Brownridge 2006). As a counselor, 

additional screening questions tailored to 

address unique vulnerabilities associated 

with the specific physical disability may be 

warranted. For example, 

• 	 Has anyone ever withheld food or 

medication from you that you asked for or 

needed? 

• 	 Has anyone ever refused to let you use your 

wheelchair or other assistive devices at home 

or in the community? 

• 	 Has anyone ever refused to assist you with 

self-care that you needed, such as getting out 

of bed, using the toilet, or other personal 

care tasks? 

• 	 Has anyone used restraints on you to keep 

you from getting out of bed or out of your 

wheelchair? 

Initial questions about trauma should be general 

and gradual. While ideally you want the client to 

control the level of disclosure, it is important as 

a counselor to mediate the level of disclosure. At 

times, clients with PTSD just want to gain relief; 

they disclose too much, too soon without having 

established trust, an adequate support system, 

or effective coping strategies. 

Preparing a woman to respond to trauma-


related questions is important. By taking the 


time with the client to prepare and explain 

how the screening is done and the potential 

need to pace the material, the woman has 

more control over the situation. Overall, she 

should understand the screening process, why 

the specific questions are important, and that 

she can choose not to answer or to delay her 

response. From the outset, counselors need to 

provide initial trauma-informed education and 

guidance with the client. 

Eating Disorders 

Eating disorders have one of the highest 

mortality rates of all psychological disorders 

(Neumarker 1997; Steinhausen 2002). 

Approximately 15 percent of women in 

substance abuse treatment have had an eating 

disorder diagnosis in their lifetimes (Hudson 

1992). Three eating disorders are currently 

included in the DSM-IV-TR: anorexia nervosa, 

bulimia nervosa, and eating disorder not 

otherwise specified (APA 2000a). Compulsive 

eating, referred to as 

binge-eating disorder, 

is not included as 

a diagnosis in the 

DSM. Currently, it is 

theorized that substance 

use disorders and 

compulsive overeating 

are competing disorders, 

in that compulsive 

overeating (bingeeating) is not as likely 

to appear at the same 

time as substance use 

disorders. Consequently, 

disordered eating in 

72 Screening and Assessment 
Figure 4-8 

General and Specific Screening Questions for Persons With Possible 

Eating Disorders


General Screening Questions 

• How satisfied are you with your weight and shape? 

• How often do you try to lose or gain weight? 

• How often have you dieted? 

• What other methods have you used to lose weight? 

Specifi c Screening Questions 

• Have you ever lost weight and weighed less than others thought you should weigh? 

• Have you had eating binges in which you eat a large amount of food in a short period of time? 

• Do you ever feel out of control when eating? 

• Have you ever vomited to lose weight or to get rid of food that you have eaten? 

• What other sorts of methods have you used to lose weight or to get rid of food? 

Source: CSAT 2005e. 

the form of compulsive overeating is more 

likely to appear after a period of abstinence, 

thus enhancing the risk of relapse to drugs and 

alcohol to manage weight gain. 

Bulimia nervosa, characterized by recurrent 

episodes of binge and purge eating behaviors, 

has the highest incidence rates in the general 

population for eating disorders (Hoek and 

van Hoeken 2003), and it is the most common 

eating disorder among women in substance 

abuse treatment (Corcos et al. 2001; Specker et 

al. 2000; APA 2000a). For specifi c information 

regarding the co-occurring disorders of eating 

and substance use disorders, counselors should 

refer to TIP 42 Substance Abuse Treatment for 

Persons With Co-Occurring Disorders (CSAT 

2005e). 

Screening for eating disorders in substance 

abuse treatment is based on the assumption that 

identification of an eating disorder can lead 

to earlier intervention and treatment, thereby 

reducing serious physical and psychological 

complications and decreasing the potential risk 

for relapse to manage weight. Eating disorder 

screenings are not designed to establish an 

eating disorder diagnosis but instead to identify 

the need for additional psychological and 

medical assessments by a trained mental health 

clinician and medical personnel. The EAT-26 

(Garner et al. 1982), or Eating Attitudes Test, 

is a widely used screening tool that can help 

identify behaviors and symptoms associated 

with eating disorder risk (Garner et al. 1998). 

It is recommended that a two-stage process be 

employed using the EAT-26: screening followed 

by a clinical interview. Specifically, if the woman 

scores at or above a cutoff score of 20 on the 

EAT-26, she should be referred for a diagnostic 

interview. For a copy of the screening tool and 

scoring instructions, refer to Appendix C. 

Figure 4-8 lists questions that probe for an 

eating disorder. A woman with an eating 

disorder often feels shame about her behavior, 

so the general questions help ease into the topic 

as the counselor explores the client’s attitude 

toward her shape, weight, and dieting. 

Screening by Healthcare Providers 

in Other Settings 

Healthcare providers such as nurse 

practitioners, physicians, physicians’ 

assistants, and social service professionals have 

opportunities to screen women to determine 

whether they use or abuse alcohol, drugs, or 

tobacco. The most frequent points of entry 

Screening and Assessment 73 
Our own 

preconceived images 

of women who are 

addicted, coupled 

with a myth that 

women are less likely 

to become addicted, 

can undermine 

clinical judgment 	

to conduct routine 


screenings for 

substance use. 

from other systems of 

care are obstetric and

primary care; hospital 

emergency rooms;

probation offi cer visits; 

and social service

agencies in connection 

with housing, child

care, and domestic 

violence. 

Between 5 and 40 

percent of people

seeing physicians and/ 

or reporting to hospital

emergency rooms for 

care have an alcohol 

use disorder (Chang 

1997), but physicians 

often do not identify, 

refer, or intervene 

with these patients

(Kuehn 2008). Even 


clinicians who often


use the CAGE or other 

screening tools for

certain patients are less 

likely to ask women 

these questions because 

women—particularly older women, women 

of Asian descent, and those from middle and 

upper socioeconomic levels—are not expected 

to abuse substances (Chang 1997). Volk and 

colleagues (1996) found that, among primary 

care patients who were identified as “at risk” 

for alcohol abuse or dependence by a screening 

questionnaire, men were 1.5 times as likely as 

women to be warned about alcohol use and 

three times as likely to be advised to stop or 

modify their consumption. Women may be less 

likely to have problems with alcohol or drugs 

than men (Kessler et al. 1994, 1995); however, 

when women have substance use disorders, 

they experience greater health and social 

consequences. 

Screening must lead to appropriate referrals 

for further evaluation and treatment in order 

to be worthwhile. Missed opportunities can 

be especially unfortunate during prenatal 

care. In one study of ethnically diverse women 

reporting to a university-based obstetrics clinic, 

38 percent screened positive for psychiatric 

disorders and/or substance abuse. However, 

only 43 percent of those who screened positive 

had symptoms recorded in their chart, and only 

23 percent of those screening positive were given 

treatment. This low rate of treatment is of great 

concern, given the untoward consequences of 

substance use for maternal and infant health 

(Kelly et al. 2001). 

To address the disconnection that often happens 

(beginning with the lack of identifi cation of 

substance-related problems of the patient and 

extending to the failure of appropriate referrals 

and brief interventions), SAMHSA has invested 

in the Screening, Brief Intervention, and 

Referral to Treatment Initiative (SBIRT)— 

research, resources development, training, and 

program implementation across healthcare 

settings. Although studies have not focused on 

gender comparisons, SBIRT programs have 

yielded short-term improvements in individual 

health (for review, see Babor et al. 2007). 

Specifically, some SBIRT programs on the State 

level have tailored SBIRT to provide assistance 

to pregnant women (Louisiana Department of 

Health and Hospitals 2007). 

Assessment 

The assessment examines a client’s life in 

far more detail so that accurate diagnosis, 

appropriate treatment placement, problem lists, 

and treatment goals can be made. Usually, a 

clinical assessment delves into a client’s current 

experiences and her physical, psychological, 

and sociocultural history to determine specifi c 

treatment needs. Using qualified and trained 

clinicians, a comprehensive assessment enables 

the treatment provider to determine with the 

client the most appropriate treatment placement 

and treatment plan (CSAT 2000c). Notably, 

assessments need to use multiple avenues to 

obtain the necessary clinical information, 

including self-assessment instruments, clinical 

records, structured clinical interviews, 

assessment measures, and collateral information. 

Rather than using one method for evaluation, 

74 Screening and Assessment 
Advice to Clinicians: 

Mental Health Screening and Women 

• 

• 

• 

• 

• 

• 

Women need to be routinely screened for depressive, eating, and anxiety disorders 

including PTSD. 

Women tend to report higher levels of anxiety and somatic symptoms associated with 

depression. 

Explicit details, especially related to traumatic subject matter that may make a woman 

uncomfortable, are not necessary early in the process. 

For some women, drugs have had a secondary effect and purpose, i.e., weight 

management. Be aware that weight gain during recovery can be a concern and a 

relapse risk factor for women and that clinical and medical issues surrounding body 

image, weight management, nutrition, and healthy lifestyle habits are essential 

ingredients in treatment for women. 

Bulimia nervosa is the most common eating disorder among women in substance 

abuse treatment, and counselors should become knowledgeable about the specifi c 

behavioral patterns associated with this disorder, e.g., compensatory and excessive 

exercise for overeating, routine pattern of leaving after meals, persistent smell of 

vomit on the woman’s breath or in a particular bathroom, taking extra food (from 

dining room), or hoarding food, etc. 

Be aware that women with bulimia nervosa are usually of normal weight. 

assessments should include multiple sources 

of information to obtain a broad perspective 

of the client’s history, level of functioning and 

impairment, and degree of distress. 

Assessment should be a fluid process throughout 

treatment. It is not a once-and-done event. 

Considering the complexity of withdrawal and 

the potential influence of alcohol and drugs 

on physical and psychological functioning, it 

is very important to reevaluate as the client 

engages into recovery. Periodic reassessment 

is critical to determine the client’s progress 

and her changing treatment needs. In addition, 

reassessment is an opportunity to solicit input 

from the client on what is and is not working 

for her in treatment and to alter treatment 

accordingly. 

The following section reviews core assessment 

processes tailored for women, including genderspecific content for biopsychosocial histories and 

assessment tools that are either appropriate or 

possess normative data for women in evaluating 

substance use disorders and consequences. It 

is beyond the scope of this chapter to provide 

specific assessment guidelines or tools for other 

disorders outside of substance-related disorders. 

The Assessment Interview 

To provide an accurate picture of the client’s 

needs, a clinical assessment interview requires 

sensitivity on the part of the counselor and 

considerable time to complete thoroughly. While 

treatment program staff may have limited time 

or feel pressure to conduct initial psychosocial 

histories quickly, it is important to portray to 

clients that you have sufficient time to devote 

to the process. The assessment interview is the 

beginning of the therapeutic relationship and 

helps set the tone for treatment. 

Initially, the interviewer should explain the 

reason for and role of a psychosocial history. 

It is equally important that the counselor or 

intake worker incorporate screening results 

into the interview, and make the appropriate 

referrals within and/or outside the agency to 

comprehensively address presenting issues. The 

notion that the women’s substance use is not 

an isolated behavior but occurs in response to, 

Screening and Assessment 75 
Advice to Administrators: 

General Guidelines for Selecting and Using Screening 

and Assessment Tools 

• What are the goals of the screening and assessment?

• Is the screening and assessment process appropriate for the particular setting with

women? 

• What costs are associated with the screening process; e.g., training, buying the

screening/assessment instruments or equipment (computer), wages associated with 

giving and scoring the instrument, and time spent providing feedback to the client 

and establishing appropriate referrals? 

• What other staff resources are needed to administer and score the instrument, 

interpret the results, review the findings with the client, arrange referrals, or establish 

appropriate services to address concerns highlighted in the screening and assessment 

process? 

• While screening measures can be completed in just a few minutes, positive screenings

involve more work. Does staff see a need for and value of the additional work? 

Did you prepare and train staff? What strategies did you employ to obtain staff or 

administrative buy-in? What other obstacles have you identified if the screening is 

implemented? Have you developed strategies to target their specifi c obstacles? 

• Do you have a system in place to manage the results of the screening and assessment

process? 

Note: While formal assessment tools are consistently used in research associated 

with substance use disorders, treatment providers and counselors are less likely to 

use formalized tools and more likely to only use clinical interviews (Allen 1991). The 

standardization of formal assessment measures offers consistency and uniformity in 

administration and scoring. If the implementation of these tools is not cost prohibitive 

and staff maintain adherence to administration guidelines, formal assessment tools can 

be easily adopted regardless of diverse experience, training, and treatment philosophy 

among clinicians. Using psychometrically sound instruments can offset clinical bias and 

provide more credibility with clients. 

and affects, other behaviors and areas of her 

life is an important concept to introduce during 

the intake phase. This information can easily 

disarm a client’s defensiveness regarding use 

and consequences of use. 

The focus of the assessment may vary depending 

on the program and the specific issues of an 

individual client. A structured biopsychosocial 

history interview can be obtained by using 

The Psychosocial History (PSH) assessment 

tool (Comfort et al. 1996), a comprehensive 

multidisciplinary interview incorporating 

modifications of the Addiction Severity Index 

(ASI) designed to assess the history and needs 

of women in substance abuse treatment. 

Investigators have sought to retain the 

fundamental structure of ASI while expanding 

it to include family history and relationships, 

relationships with partners, responsibilities for 

children, pregnancy history, history of violence 

and victimization, legal issues, and housing 

arrangements (Comfort and Kaltenbach 1996). 

PSH has been found to have satisfactory testretest reliability (i.e., the extent to which the 

scores are the same on two administrations of the 

instrument with the same people) and concurrent 

validity with the ASI (Comfort et al. 1999). 

76 Screening and Assessment 
Psychosocial and Cultural History 

Treatment programs have their own prescribed 

format for obtaining a psychosocial history 

that coincides with State regulations as well 

as other standards set by Joint Commission 

on Accreditation of Healthcare Organizations 

(JCAHO) and Commission on Accreditation 

of Rehabilitation Facilities (CARF). While 

many States require screening and assessment 

for women, specific guidelines and specifi city 

in incorporating women-specific areas vary 

in degree (CSAT 2007). Note: When using 

information across State standards, the 

following psychosocial and cultural subheadings 

should be included in the initial assessment for 

women, and these areas need to be addressed 

in more depth as treatment continues. Keep in 

mind that the content within each subheading 

does not represent an entire psychosocial and 

cultural history. Only biopsychosocial and 

cultural issues that are pertinent to women 

were included in the list below. 

Medical History and Physical Health: Review 

HIV/AIDS status, history of hepatitis or 

other infectious diseases, and HIV/AIDS risk 

behavior; explore history of gynecological 

problems, use of birth control and hormone 

replacement therapy, and the relationship 

between gynecological problems and substance 

abuse; obtain history of pregnancies, 

miscarriages, abortions, and history of 

substance abuse during pregnancy; assess need 

for prenatal care. 

Substance Abuse History: Identify people who 

initially introduced alcohol and drugs; explore 

reasons for initiation of use and continued use; 

discuss family of origin history of substance 

abuse, history of use in previous and present 

significant relationships, and history of use with 

family members or signifi cant others. 

Mental Health and Treatment History: Explore 

prior treatment history and relationships with 

prior treatment providers and consequences, 

if any, for engaging in prior treatment; review 

history of prior traumatic events, mood or 

anxiety disorders (including PTSD), as well 

as eating disorders; evaluate safety issues 

including parasuicidal behaviors, previous 

or current threats, history of interpersonal 

violence or sexual abuse, and overall feeling of 

safety; review family history of mental illness; 

and discuss evidence and history of personal 

strengths and coping strategies and styles. 

Interpersonal and Family History: Obtain 

history of substance abuse in current 

relationship, explore acceptance of client’s 

substance abuse problem among family and 

significant relationships, discuss concerns 

regarding child care needs, and discuss the 

types of support that she has received from 

her family and/or significant other for entering 

treatment and abstaining from substances. 

Family, Parenting, and Caregiver History: 

Discuss the various caregiver roles she may play, 

review parenting history and current living 

circumstances. 

Children’s Developmental and Educational 

History (applicable to women and children 

programs): Assess child safety issues; explore 

developmental, emotional, and medical needs of 

children. 

Sociocultural History: Evaluate client’s 

social support system, including the level of 

acceptance of her recovery; discuss level of 

social isolation prior to treatment; discuss the 

role of her cultural beliefs pertaining to her 

substance use and recovery process; explore 

the specific cultural attitudes toward women 

and substance abuse; review current spiritual 

practices (if any); discuss current acculturation 

conflicts and stressors; and explore need or 

preference for bilingual or monolingual nonEnglish services. 

Vocational, Educational, and Military History: 

If employed, discuss the level of support that 

the client is receiving from her employer; review 

military history, then expand questions to 

include history of traumatic events and violence 

during employment and history of substance 

abuse in the military; assess fi nancial selfreliance. 

Legal History: Discuss history of custody and 

current involvement with child protective 

services, if any; obtain a history of restraining 

orders, arrests, or periods of incarceration, 

Screening and Assessment 77 
TIPs that provide assessment information relevant to 

women in specifi c settings: 

TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs,
 

2005 


TIP 44 Substance Abuse Treatment for Adults in the Criminal Justice System, 2005 

TIP 45 Detoxification and Substance Abuse Treatment, 2006 

TIP 49 Incorporating Alcohol Pharmacotherapies Into Medical Practice, 2009b 

Additional TIPs that address assessment strategies and tools for co-occurring 


disorders and interpersonal childhood and adult violence that are highly 


prevalent among women: 


TIP 25 Substance Abuse Treatment and Domestic Violence, 1997 

TIP 36 Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues, 2000 

TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders, 2005 

TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, 2009a 

Planned TIP, Substance Abuse and Trauma, in development h 

if any; determine history of child placement 

with women who acknowledge past or current 

incarceration. 

Barriers to Treatment and Related 

Services: Explore financial, housing, health 

insurance, child care, case management, and 

transportation needs; discuss other potential 

obstacles the client foresees. 

Strengths and Coping Strategies: Discuss the 

challenges that the client has faced throughout 

her life and how she has managed them, review 

prior attempts to quit substance use and identify

strategies that did work at the time, identify 

other successes in making changes in other areas 

of her life. 

Assessment Tools for Substance 

Use Disorders 

Addiction Severity Index (ASI): The ASI 

(McLellan et al. 1980) is the most widely used 

substance abuse assessment instrument in both 

research and clinical settings. It is administered 

as a semi-structured interview and gathers 

information in seven domains (i.e., drug use, 

alcohol use, family/social, employment/fi nances, 

medical, psychiatric, and legal). The ASI has 

demonstrated high levels of reliability and

validity across genders, races/ethnicities, types

of substance addiction, and treatment settings

(McCusker et al. 1994; McLellan et al. 1985;

Zanis et al. 1994; See Appendix C for specifi c 

information on the ASI). 

ASI-F (CSAT 1997c): The ASI-F is an expanded

version of ASI; several items were added

relevant to the family, social relationships, and 

psychiatric sections. Additional items refer to

homelessness; sexual harassment; emotional,

physical, and sexual abuse; and eating disorders.

The supplemental questions are asked after the 

administration of ASI. Psychometric data for

ASI-F are limited. 

Texas Christian University Brief Intake, 

the Comprehensive Intake, and Intake for 

Women and Children: These instruments are 

available electronically and are administered 

by a counselor. The seven problem areas in 

the Brief Intake Interview were derived from 

78 Screening and Assessment 
the ASI: drug, alcohol, 

medical, psychological,

employment, legal, and 

family/social. Scoring

is immediate, and the 

program generates a

one-page summary of 

the client’s functioning 

in 14 domains (Joe 

et al. 2000). The

Comprehensive Intake 

has an online version for 

women (Simpson and 

Knight 1997; For review, 

visit: http://www.utexas. 

edu/research/cswr/nida/ 

instrumentListing.html).

Drinker Inventory of 

Consequences (DrinC): 

This measurement is 

a self-administered 

Since women are 

more likely to 

experience greater 

consequences earlier 

than men, using 

an instrument that 

highlights specifi c 	

consequences of use 

is crucial.	 

50-item, true-false questionnaire that elicits 

information about negative consequences 

of drinking in five domains: physical, 

interpersonal, intrapersonal, impulse control, 

and social responsibility (Miller et al. 1995). 

This instrument has normative data for women, 

men, inpatient and outpatient, and has good 

psychometric properties. Since women are 

more likely to experience greater consequences 

earlier than men, using an instrument that 

highlights specific consequences of use is crucial. 

A version that assesses drug use consequences 

is also available (Tonigan and Miller 2002). 

For a copy of the assessment tool, scoring, and 

gender profile in interpreting severity of lifetime 

consequences, see Appendix C. 

Available screening and 

assessment tools: Language 

availability 

Figure 4-9 (p. 80) provides available 

information on screening and assessment 

versions in languages other than English. This 

is not an exhaustive list, and counselors and 

administrators should not assume language 

availability is a sign that the instrument is 

appropriate for a particular culture, ethnic, or 

racial group. 

Other Considerations in 

Assessment: Strengths, Coping 

Styles, and Spirituality 

Looking at women’s strengths 

Focusing on a woman’s strengths instead of 

her deficits improves self-esteem and selfefficacy. Familiarity with a woman’s strengths 

enables the counselor to know what assets the 

woman can use to help her during recovery. In 

the Woman’s Addiction Workbook (Najavits 

2002a), the author provides a self-assessment 

worksheet that focuses on individual strengths. 

In addition to assessing strengths, coping styles 

and strategies should be evaluated (see Rotgers 

2002). 

Measurements of spirituality and 

religiousness 

Spirituality and religion play an important 

role in culture, identity, and health practices 

(Musgrave et al. 2002). In addition, women 

are more likely to embrace different coping 

strategies (including emotional outlets and 

religion) to assist in managing life stressors 

(Dennerstein 2001). Practices such as 

consulting religious leaders or spiritual healers 

(curanderas, medicine men) and attending 

to spiritual activities (including sweats and 

prayer ceremonies, praying to specific saints or 

ancestors) are common. The consensus panel 

believes it is important that programs assess 

the spiritual and religious beliefs and practices 

of women and incorporate this component into 

their treatment with sensitivity and respect. 

A challenge in determining the effect of 

spirituality on treatment outcomes is how to 

assess the extent and nature of a person’s 

spirituality or religiousness. Several assessment 

tools are available; however, they are more 

often used for research. They include, but 

are not limited to, the Religious Practice and 

Beliefs measurement (CASAA 2004), a 19­

item self-assessment tool that reviews specifi c 

activities associated with religious practices; 

the Multidimensional Measure of Religiousness/ 

Spirituality, an assessment device that examines 

domains of religious or spiritual activity such as 

Screening and Assessment 79 
Figure 4-9 

Available Screening and Assessment Tools 

in Multiple Languages 

Instrument Language 

Addiction Severity Index Spanish 

Alcohol Use Disorders Identifi cation Test 

(AUDIT) 

Numerous language versions including Spanish, 

French, German, Russian, Chinese, etc. 

Beck Depression Inventory (BDI) 

Numerous language versions including Spanish, 

French, German, Swedish, Chinese, Korean, etc. 

Brief Symptom Inventory (BSI) Spanish and French 

CAGE 

Numerous language versions including Spanish, 

Flemish, French, Hebrew, Japanese, etc. 

Eating Attitudes Test (EAT-26) 

Numerous language versions including Spanish 

and Japanese 

General Health Questionnaire (GHQ) 

Numerous language versions including Spanish, 

Japanese, Chinese, Farsi, etc. 

Mini International Neuropsychiatric 

Interview (MINI) 

Available in 43 languages including Spanish 

Spiritual Well-Being Scale Spanish 

Texas Christian University Drug Screen II 

(TCUII) 

Spanish 

TWEAK Spanish 

daily spiritual experiences, values and beliefs, 

and religious and spiritual means of coping 

(Fetzer Institute 1999); and the Spiritual WellBeing Scale, a 20-item scale that examines the 

benefits of spirituality for African-American 

women in recovery from substance abuse 

(Brome et al. 2000; See Appendix C for specifi c 

information on the Spiritual Well-Being Scale). 

Health Assessment and Medical 

Examination 

Because women develop serious medical 

problems earlier in the course of alcohol use 

disorders than men, they should be encouraged 

to seek medical treatment early to enhance 

their chances of recovery and to prevent serious 

medical complications. Health screenings and 

medical examinations are essential in women’s 

treatment. In particular, women entering 

substance abuse treatment programs should be 

referred for mental health, medical, and dental 

examinations. In many cases, they may not have 

had adequate health care because of lack of 

insurance coverage or transportation, absence 

of child care, lack of time for self-care, chaotic 

lifestyle related to a substance abuse, or fear of 

legal repercussions or losing custody of children. 

The acute and chronic effects of alcohol and 

drug abuse, the potential for violence, and other 

physical hardships (e.g., homelessness) greatly 

increase the risk for illness and injury. 

Women may practice behaviors that put them at 

high risk for contracting sexually transmitted 

diseases (STDs) and other infectious diseases 

80 Screening and Assessment 
Advice to Clinicians: 

General Guidelines of Assessment for Women 

• 	 Similar to the screening process, women should know the purpose of the assessment. 

• 	 To conduct a good quality assessment, counselors need to value and invest in the 

therapeutic alliance with the client. Challenging, disagreeing, being overly invested in 

the outcome, or vocalizing and assuming a specific diagnosis without an appropriate 

evaluation can quickly erode any potential for a good working relationship with the 

client. 

• 	 The assessment process should include various methods of gathering information: 

clinical interview; assessment tools including rating scales; behavioral samples 

through examples of previous behavior or direct observation; collateral information 

from previous treatment providers, family members, or other agencies (with client 

permission); and retrospective data including previous evaluations, discharge 

summaries, etc. 

• 	 Assessment is only as good as the ability to follow through with the 

recommendations. 

• 	 Assessments need to incorporate sociocultural factors that may infl uence behavior 

in the assessment process, interpretation of the results, and compliance with 

recommendations. 

• 	 The assessment process should extend beyond the initial assessment. As the 

woman becomes more comfortable, additional information can be gathered and 

incorporated into the revised assessment. Subsequently, this new information will 

guide the reevaluation of presenting problems, treatment priorities, and treatment 

planning with input and guidance from the client. 

• 	 Reassessments help monitor progress across the continuum of care and can be used 

as a barometer of effective treatment. Moreover, the presenting problems and 

symptoms may change as recovery proceeds. 

(Greenfield 1996). Testing for HIV/AIDS, 

hepatitis, and tuberculosis is important; 

however, it is as essential to have adequate 

support services to help women process test 

results in early recovery. Anticipation of the 

test results is stressful and may place the client 

at risk for relapse. Residential centers may 

offer medical exams onsite, but outpatient 

service providers may need to refer patients 

to their primary care provider or other 

affordable health care to ensure that each 

client has a thorough medical exam. Healthcare 

professionals may benefit in using the WomenSpecific Health Assessment (Stevens and Murphy 

1998), which assesses health and wellness and 

addresses gynecological exams, HIV/AIDS, drug 

use, STDs, pregnancy/child delivery history, 

family planning, mammography, menstruation, 

disease prevention, and protection behaviors. 

Screening and Assessment 81 
In This
 

Chapter
 

Barriers to Treatment 


Engagement
 

Treatment 


Engagement Strategies
 

Considerations in 


Treatment Placement 


and Planning
 

Levels of Care
 

5 Treatment 

Engagement, 

Placement, and 

Planning 

Overview 

Women often encounter numerous obstacles and barriers prior to and 

during the treatment process. While these hurdles may not be entirely 

unique to women, they are often more common for women due to the 

myriad pressures associated with assuming various caregiver roles, 

intrinsic socioeconomic and health conditions (particularly for women 

with substance use disorders), and societal bias and stigma associated 

with substance abuse. These challenges often interfere with treatment 

initiation and engagement. 

This chapter is devoted to the exploration of treatment barriers as 

well as to the engagement strategies conducive to supporting treatment 

initiation for women. Considerations in treatment placement and the 

importance of client involvement are reviewed. The chapter ends 

with an overview of American Society of Addiction Medicine (ASAM) 

placement criteria for each treatment level with emphasis on issues 

specific to women, pregnant women, and women and children. 

Barriers to Treatment Engagement 

Making a decision to change is an essential step toward fulfi lling any 

goal, but is only one ingredient of a successful outcome. Many times, 

the idea of making a change is shortsighted: How often has a decision 

been made without looking beyond the initial necessity or enthusiasm 

for the change? To support change across time, obstacles need to be 

anticipated and strategies need to be developed either to decrease the 

occurrence of the barriers or to find alternative routes around the 

potential obstacles. 

Treatment Engagement, Placement, and Planning 83 
Barriers to treatment are not exclusive to 

women (for review, see Appel et al. 2004), 

yet identifying potential challenges and 

obstacles can help enable successful treatment 

engagement and outcome. Historically, women 

have identified multiple factors as barriers to 

entering treatment, to engaging and continuing 

the utilization of treatment services across 

the continuum of care, and in maintaining 

connections with community services and selfhelp groups that support long-term recovery (see 

Figure 5-1 for an overview of barriers identifi ed 

in the Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s) National 

Survey on Drug Use and Health [NSDUH]). 

While the identification of barriers is essential 

to effective case management and treatment 

planning, it is equally important to develop 

specific strategies to address each barrier as 

early as possible. As highlighted in the Center 

for Substance Abuse Treatment’s (CSAT’s) 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children (for 

review, see Appendix B; HHS 2004), strategies 

to overcome these barriers need to focus on 

three core areas: clinical treatment services, 

clinical support services, and community 

support systems. Without a proactive plan to 

address barriers, women will not be as able 

to engage in or benefit from substance abuse 

treatment. 

At the outset, barriers may exist on several 

levels: 

• 	 Intrapersonal: Individual factors including 

health problems, psychological issues, 

cognitive functioning, motivational status, 

treatment readiness, etc. 

• 	 Interpersonal: Relational issues including 

significant relationships, family dynamics, 

support systems, etc. 

• 	 Sociocultural: Social factors including 

cultural differences; the role of stigma, bias, 

and racism; societal attitudes; disparity 

in health services; attitudes of healthcare 

providers toward women; and others. 

• 	 Structural: Program characteristics 

including treatment policies and procedures, 

program design, and treatment restrictions. 

• 	 Systemic: Larger systems including Federal, 

State, and local agencies that generate 

public policies and laws; businesses 

including health insurance companies; and 

environmental factors such as the economy, 

drug trafficking patterns, etc. 

Intrapersonal Obstacles 

Various individual factors impede interest in 

and commitment to entering treatment. The 

anticipation of not being able to use substances 

to cope with stress, to manage weight, or to deal 

with symptoms associated with other mental 

disorders creates considerable apprehension in 

making a commitment to treatment. While the 

level of motivation and the degree of treatment 

readiness may also obstruct a woman’s 

commitment to treatment (Miller and Rollnick 

2002), there are other individual characteristics 

that may serve as a barrier to treatment, 

including feelings related to previous treatment 

failures, feelings of guilt and shame regarding 

use and behavior associated with use, fear of 

losing custody of children if the drug or alcohol 

problem is admitted and treatment is sought, 

feelings of helplessness, and a belief that change 

is not possible (Allen 1995; Greenfi eld 1996). 

Moreover, health issues can serve as a powerful 

roadblock for women. Depending on the 

medical diagnosis and severity of the disorder, 

women may encounter difficulties in accessing 

treatment, securing appropriate services, and 

coordinating medical and substance abuse 

treatment needs. Many women neglect their 

health while they are actively using substances, 

hence treatment entry may be delayed or 

difficult to coordinate due to the additional 

burden imposed by health issues (including 

HIV/AIDS, viral hepatitis and other infectious 

diseases, mental disorders, and gynecological 

and obstetric needs). Thus, poor physical health 

may hinder entry into treatment (Jessup et al. 

2003). 

Interpersonal Obstacles 

Because women are usually the primary 

caregivers of children as well as of other 

family members, they are often unable or not 

84 Treatment Engagement, Placement, and Planning 
 

Figure 5-1 

Percentages of Reasons for Not Receiving Substance Use Treatment in 

the Past Year Among Women Aged 18 to 49 Who Needed Treatment 

and Who Perceived a Need for It: 2004–2006 

Not Ready to Stop Using 

Cost/Insurance Barriers 

Social Stigma 

Did Not Feel Need for Treatment/Could 

Handle the Problem without Treatment 

Did Not Know Where to Go for Treatment 

Did Not Have Time 

Treatment Would Not Help 

Other Access Barriers 

0% 10% 20% 30% 40% 

15.5 

4.7 

2.7 

15.7 

13.2 

28.9 

34.4 

36.1 

Sources: SAMHSA 2004, 2005, 2006. 

encouraged to enter and remain in treatment. 

Also, sometimes their families and friends are 

involved with substance use and abuse. Further, 

women may share a social network in which 

drug or alcohol use is a central activity. This 

group of family and friends may see no benefi t 

in and offer no encouragement for becoming 

alcohol and drug free (Amaro and HardyFanta 1995; Finkelstein 1993; Salmon et al. 

2000). While women report fear of losing their 

partner during treatment, they are particularly 

vulnerable to losing their partner upon entering 

treatment (Lex 1991). In addition, women 

generally fear family or partner reactions or 

resistance to asking for help outside the family. 

Sociocultural Obstacles 

Women are more stigmatized by alcohol and 

illicit drug use than men, being characterized 

sometimes as morally lax, sexually promiscuous, 

and neglectful as mothers. In addition, women 

who have children often fear that admitting 

a substance use problem will cause them to 

lose custody of their children. They worry 

that they will be perceived as irresponsible or 

neglectful—as “bad mothers” if they admit to 

substance abuse or dependence. These fears 

and stereotypes compound a woman’s shame 

and guilt about substance use (Finkelstein 1994) 

and subsequently interfere with help-seeking 

behavior. 

To compound the issue, women in some cultural 

groups experience more negative attitudes 

toward their substance use in general and 

may express more difficulty in engaging in 

help-seeking behavior and treatment services 

based on gender roles and expectations. For 

example, Asian women, in conjunction with 

cultural practices and level of acculturation, 

may have considerable difficulty in engaging 

in mix-gender groups due to the value placed 

upon male offspring, gender role expectations, 

and patriarchal family hierarchy (Chang 2000). 

African-American and Native-American women 

Treatment Engagement, Placement, and Planning 85 
are likely to mistrust 

treatment services. 

Specifi cally, Jumper 

Thurman and Plested

(1998) reported that 

Native-American women

list mistrust as one of 

the primary barriers to

engaging in treatment 

services. A more recent 

study evaluating barriers 

among African-American 

women identifi ed staff 

attitudes as a signifi cant 

obstacle in maintaining 

treatment engagement 

and retention (Roberts 

and Nishimoto 2006). 

The barriers 	

that exist before 

treatment are often 

the same obstacles 

that interfere 

with successfully 

completing treatment 

or maintaining 

abstinence.	 Similar to men, women 

may face language and 

cultural barriers that 

impede involvement or retention in substance 

abuse treatment. Women whose fi rst language 

is not English may have language diffi culties 

(Mora 2002). Women with specific needs or from 

specific groups can face social indifference, lack 

of culturally appropriate programming, and 

limited cultural competence among staff. For 

example, lesbians who are seeking treatment 

may not trust the service provider or treatment 

staff to appropriately handle their personal 

information in a group setting––fearing their 

sexual orientation will be prematurely disclosed. 

Structural Obstacles 

According to SAMHSA’s 2005 National Survey 

of Substance Abuse Treatment Services, 87 

percent of these programs accepted women as 

clients, but only 41 percent provided special 

programs or groups for women. Overall, only 

17 percent of treatment facilities offered groups 

or programs for pregnant or postpartum women 

(SAMHSA 2006). Being responsible for the 

care of dependent children is one of the biggest 

barriers to women entering treatment (Wilsnack 

1991). Women who do not have access to a 

treatment program that provides child care or 

who cannot arrange alternative child care may 

have to choose between caring for their children 

or entering treatment. 

Unfortunately, few residential programs have 

provisions that allow mothers to have their 

children with them, and outpatient programs 

often do not provide services for children or 

child care (Drabble 1996; Finkelstein 1994; 

Finkelstein et al. 1997). Only 8 percent of 

substance abuse treatment facilities provided 

child care in 2003, and only 4 percent provided 

residential beds for clients’ children (SAMHSA 

2004). Even when children are accepted into 

residential treatment, programs often impose 

age restrictions and limit the number of children 

a mother is permitted to bring to treatment. 

Treatment resources for pregnant women 

who abuse substances are also scarce. Few 

programs can simultaneously combine the 

necessary prenatal care with substance abuse 

treatment and services for older children 

(Amaro and Hardy-Fanta 1995; Finkelstein 

1993). Finkelstein (1993) stresses that the major 

barriers to providing resources for pregnant 

women are based on administrative concerns 

about medical issues for mothers, infants, and 

children; fear of program liability; inability to 

care for infants and lack of services for other 

children while mothers are in treatment; lack 

of financial resources; and limited staff training 

and knowledge about pregnancy and substance 

use. 

Substance abuse treatment providers may 

not fully understand the needs and the types 

of interventions most conducive to assisting 

women in recovery. Vannicelli (1984) found that 

treatment staff attitudes and unsubstantiated 

myths about women actually may act as barriers 

to successful treatment completion among 

women. In addition, programs may lack cultural 

competence in addressing treatment issues for 

women from different cultural or language 

backgrounds; thus ethnic women may be 

reluctant to seek treatment if treatment staff or 

the programs feel foreign, judgmental, hostile, 

or indifferent. 

Even women who are highly motivated for 

treatment face additional program barriers 

86 Treatment Engagement, Placement, and Planning 
that may produce significant challenges. These 

barriers include waiting lists, delayed admission, 

limited service availability, and preadmission 

requirements (e.g., paperwork requirements, 

detoxification). Other barriers are related to 

program structure, policies, and procedures 

and include program location, lack of case 

management services, limited funding sources, 

and lack of transportation (Wechsberg et al. 

2007). Because women are more likely to be 

poor, their ability to obtain transportation may 

make it difficult to receive treatment (Lewis et 

al. 1996). Also, women may have to travel with 

their children and use public transportation 

to reach treatment agencies; this can be a 

hindrance for women in rural areas and for 

those who have limited income. 

Treatment services continue to struggle to 

effectively broaden the scope of clinical services, 

secure adequate resources, and adopt genderresponsive policies to address co-occurring 

disorders. While more programs have endorsed 

trauma-informed services in conjunction with 

programming for women, the coordination and 

integration of these specific services remains 

limited. In addition to the barriers mentioned 

above, others may exist regarding compliance 

with the Americans with Disabilities Act, such 

as no translators for women who are deaf, lack 

of materials for individuals who are visually 

impaired, and lack of treatment program 

policies and procedures and acceptance of 

women who are using methadone maintenance. 

Systems Obstacles 

Many women in need of treatment are involved 

in multiple social service systems that have 

different expectations and purpose. According 

to Young and Gardner (1997), the co-occurrence 

of a substance use disorder and involvement 

in the child welfare system ranges from 50 to 

80 percent. Moreover, collaboration among 

substance abuse treatment, child welfare, 

and welfare reform systems is challenging and 

often not integrated because of differences in 

timetables, definition of clients, complexity of 

client needs, staff education and training, and 

funding streams (Goldberg 2000; Young et al. 

1998). 

Services may be fragmented, requiring a woman 

to negotiate a maze of service agencies to obtain 

assistance for housing, transportation, child 

care, substance abuse treatment, vocational 

training, education, and medical care. In 

addition, many agencies have requirements that 

conflict with each other or endorse repetitive 

intake processes, including different forms that 

gather the same information. Overall, these 

simultaneous demands can discourage a woman, 

particularly when seeking treatment or during 

early recovery. 

Women who have substance use disorders often 

fear legal consequences. In entering treatment, 

they sometimes risk losing custody of their 

children as well as public assistance support 

(Blume 1997). Likewise, women who have 

substance use disorders often fear prosecution 

and incarceration if they seek treatment during 

pregnancy. The public debate over privacy and 

the fetus’s right to be born free from harm fuels 

a legal focus on pregnant women who smoke, 

drink alcohol, or use illicit drugs. “These 

conflicts have impeded the diagnosis of women 

with substance abuse problems, the availability 

of services, and access to appropriate care” 

(Chavkin and Breitbart 1997, p. 1201). 

Treatment Engagement 

Strategies 

Treatment engagement approaches are 

important regardless of gender, yet women 

are likely to benefit from services that support 

the initiation of treatment and address the 

diverse challenges that often hamper treatment 

involvement. Engagement services include 

an array of strategies that begin in the initial 

intake and can extend across the continuum of 

care. Ultimately, they are designed to promote 

appropriate access to treatment, to increase 

treatment utilization, to promote treatment 

retention, and to enhance treatment outcome. 

Promising engagement practices have evolved 

by integrating and centralizing services to 

meet the wide range of treatment needs and 

social services for women and children (Niccols 

and Sword 2005). Today, some programs and 

Treatment Engagement, Placement, and Planning 87 
Challenges in Maintaining a Therapeutic Alliance: 

Child Welfare and Issues of Confi dentiality 

State law can require substance abuse treatment providers to report individuals for child abuse 

and neglect and to supersede Federal confidentiality laws that cover substance abuse treatment. 

It is critical, therefore, that admissions staff, program materials, and counselors clearly present 

and discuss the limits of confidentiality as regulations require. Without this explicit discussion, 

women in treatment may have questions and feel uneasy with regard to mandated reporting. For 

instance, when counselors intervene to protect a client’s children, this may seem contradictory to 

the client and raise questions about confi dentiality. 

A great barrier to treatment for women is fear of losing their children, a fear that engenders 

intense mistrust on the part of clients who are mothers. Therapeutic alliance and trust are vital 

to the treatment process, yet treatment providers must protect children. To resolve this, women 

must understand that although providers will report their concerns for the safety of children, 

providers are advocates for the women and their families (CSAT 1996; Lopez 1994; U.S. 

Department of Health and Human Services, Office for Civil Rights 2002). 

communities provide very formal strategies 

such as comprehensive case management and 

incentive programs to promote engagement 

(Jones et al. 2001). Other engagement 

strategies include more specific services such 

as transportation and escorts to appointments, 

phone calls to initiate services and to remind 

clients of appointments, and child care during 

scheduled appointments or sessions (for review, 

see Comfort et al. 2000). 

Women who are offered services during the 

intake period are more likely to engage in similar

services throughout the treatment process than 

women from a comparison group (Comfort et al. 

2000). Three core engagement strategies that are

particularly beneficial for women are outreach 

services, pre-treatment intervention groups, and

comprehensive case management. 

Outreach Services 

Women are more likely to gain awareness of 

substance abuse treatment if outreach services 

are implemented. Outreach and engagement 

services can be clinically effective in increasing 

the likelihood of entering substance abuse 

treatment, particularly for those individuals 

who are less likely to access treatment services 

(Gottheil et al. 1997). Effective outreach 

programs, such as the one described in Figure 

5-2 (p. 91), are designed to connect women to 

substance abuse treatment regardless of point 

of service entry. For example, programs that 

address domestic violence, HIV/AIDS, or crisis 

intervention can be a vital conduit for helping 

women take the first step in connecting to 

substance abuse services. 

Gross and Brown (1993) outlined three major

components of outreach: (1) identifying a

woman’s most urgent concerns and addressing 

those first, until she is ready to take on other 

issues; (2) empathizing with the woman’s fears 

and resistances, while assisting her in following 

through on commitments; and (3) assisting the 

woman in negotiating the human service system, 

particularly when the decision to seek drug 

or alcohol treatment is stymied by the lack of 

adequate, appropriate, or accessible programs 

or when relapse alienates the woman from 

institutional connections. Although outreach

appears to benefit women—in that they are 

more likely to initiate contact with treatment

providers—women’s response to outreach 

services appears related to level of readiness,

history of trauma, and degree of support. For

instance, Melchior et al. (1999) reported that

women who have a history of trauma are more

reluctant to follow through with referrals than

men. 

88 Treatment Engagement, Placement, and Planning 
Clinical Tools and Activities 

Helping Women Overcome Barriers to Treatment 

Strategy: Success Stories 

To counter stigma, counselors might provide clients with stories or information about women 

who have achieved and maintained recovery, such as Marty Mann (www.ncadd.org) or Betty 

Ford. These stories can be used to stimulate group discussions or could be a part of regular 

client readings. 

Strategy: Barriers to Treatment Assessment Tool 

Counselors can gain significant information pertaining to current, potential, or perceived 

barriers through evaluation. Beyond a comprehensive psychosocial history, counselors and 

administrators can gain insight into the current obstacles to treatment (for review, see Allen’s 

Barriers to Treatment, Appendix D). 

Strategy: Decisional Balancing Exercise 

The decisional balancing exercise was designed to identify cognitive appraisals associated with 

benefits and costs of substance use (Cunningham et al. 1997). Both cognitive–behavioral therapy 

and motivational interviewing endorse this strategy. By easily adapting this activity to analyze 

pros and cons associated with entering treatment or not entering treatment, counselors are more 

likely to discover barriers that were not identified in the initial assessment. Counselors may 

want to demonstrate the activity by using examples, such as the pros and cons of going on a diet 

or not smoking. This exercise is not a simple pros-and-cons list for one side of the argument, 

but rather it involves looking at the benefits and costs for both sides of the argument; e.g., pros 

and cons for going on a diet as well as pros and cons for not going on a diet. This is an important 

aspect of this exercise. While many issues can be identified with one side of the argument, there 

are often other subtle issues that are acknowledged by discussing both sides of the argument. 

Following is the format for the decisional balancing exercise involving the pros and cons of 

entering or not entering substance abuse treatment. 

Pros (Benefi ts) Cons (Costs) 

Entering 

Treatment 

Better role model for my children 

Knowing that I can quit 

Maybe I can do some things that I 

haven’t been able to do while I have 

been using, e.g., working toward a 

GED 

Boyfriend may leave 

Don’t like other people 

watching my children 

Not Entering 

Treatment 

Don’t have to think about my use 

Don’t have to worry about leaving 

my family 

Can continue to use 

May end up having more 

legal problems 

May lose my children 

Not HIV positive now, but 

it may happen if I continue 

to use 

Strategy: Finishing the Story Exercise 

Counselors can “reframe” a woman’s misgivings about treatment so she may see that the feared 

outcome of seeking or staying in treatment is, in reality, the likely outcome of ending or not 

starting treatment. For example, a woman who fears she will lose her children if she enters or 

Treatment Engagement, Placement, and Planning 89 
Clinical Tools and Activities 

Helping Women Overcome Barriers to Treatment (continued) 

stays in treatment should be asked to look into the future. This exercise might clarify for her 

that continued addiction virtually guarantees that she will lose her children in the long run, 

whereas treatment and recovery will most likely ensure a long-term and stable relationship with 

her children. By asking the woman to imagine how her story will end if she continues to use 

substances, she is less likely to glorify her current use and more likely to withstand the common 

hassles associated with initiating and engaging in treatment. 

Strategy: Caregiver Portrait 

Women typically assume caregiver roles that may prevent, complicate, or interfere with 

treatment. They may feel they should not leave their spouse or significant other and fear the 

consequences of doing so. In entering treatment, they may express worry because they carry the 

burden of primary caretaker for their parents, children, or other relatives. They may feel that 

they are being disloyal to friends and family members for leaving them—believing the message 

that their substance abuse problem is “not that bad.” Women may also maintain primary 

financial responsibilities for housing and food for others and fear they will not be able to provide 

support during treatment. In addition, they may worry about child care during treatment 

regardless of treatment level. Hence, beyond identifying these concerns and potential barriers, 

it is important to provide a way to discuss these as well as to determine their level of importance 

based on their perception. 

In a group setting, first introduce the idea that everyone has specific and perceived obstacles 

that can interfere with treatment and it is important to give a voice to these challenges. Next, 

state that at least one or two people will have an opportunity to create a visual picture of these 

obstacles—similar to taking a family picture. Next, ask a woman to identify each current or 

potential obstacle to treatment and assign each obstacle to a particular group member. Emphasize 

to group members that if they are selected to participate, they don’t need to say anything in this 

assigned role. This decreases anxiety and hesitancy in participating. 

After the obstacles are assigned, ask the client to arrange the obstacles (group members) as if 

she were a photographer setting up a family portrait. Remind her to arrange (only verbally 

directing other group members) the portrait in one area of the room according to how important 

she perceives the obstacles, e.g., placing the most challenging or fearful barriers in front of 

others. Next, have the client discuss each obstacle and the rationale for her placement. As the 

exercise unfolds, obstacles may end up being rearranged in the picture. In addition, counselors 

may want to help the client identify feelings related to specific obstacles in the picture by walking 

around the portrait. Other strategies may be used in conjunction with this activity including 

problemsolving, cognitive restructuring, or motivational interviewing strategies. However, it 

is often best to keep it simple and to encourage other group members to do the same exercise. 

You can involve the entire group through discussion or by using a paper-pencil drawing that 

demonstrates their barriers. While this exercise is ideal for group, you can modify it by using a 

paper-pencil drawing for individual sessions. 

Note: To reinforce appropriate boundaries, remind participants not to touch others during the 

exercise. 

90 Treatment Engagement, Placement, and Planning 
Pretreatment Intervention Groups	 that brief interventions are not consistently 

helpful for women (Chang 2002), more specifi c Early identification and intervention may research is needed to examine differences prevent more significant alcohol- and drug- in factors that influence early intervention related consequences. Pretreatment intervention outcomes, including client-matching studies groups are typically designed to initially provide targeting gender. personalized or structured feedback to clients 

about their alcohol and drug use, to provide 

information regarding available treatment Case Management 

services and treatment processes, and to utilize Comprehensive case management helps bridge 

strategies to enhance motivation and to decrease the gap between services and agencies. It is 

alcohol and drug use. Specific to women, based on the premise that services need to 

pretreatment groups are designed to address match the client’s needs rather than force the 

certain psychosocial barriers, including the client to fit into the specific services offered 

stigma that is associated with women’s substance by the agency. With the wide range of services 

use. Similar to frequent misconceptions held often warranted for most women (especially 

by clients that detoxification is treatment, for women who are pregnant or who have 

pretreatment can be perceived as treatment 	 children), comprehensive case management that 

rather than an initial step. This is particularly involves medical and social case management is 

the case with women who are either reluctant an essential ingredient (Sorensen et al. 2005). 

or suspicious to use treatment services or who According to Brindis and Theidon (1997), 

are unable to use treatment services at the time case management serves several functions and 

(Wechsberg et al. 2007). While research reports provides numerous services for the client, 

Figure 5-2 

PROTOTYPES 

The PROTOTYPES Outreach Program in Culver City, California, is a pretreatment program 

that helps women form therapeutic alliances by providing outreach services that help women 

enter treatment. 

PROTOTYPES began in 1987 in Los Angeles County with outreach to women who used 

substances and were at risk for HIV/AIDS. The pretreatment program staff grew to include more 

than two dozen outreach workers. PROTOTYPES staff see outreach as a strategy of sustained 

contact and support that helps women move from contemplation to action. 

Outreach workers learned that even though PROTOTYPES provided a healing and 

nurturing environment, a large treatment program of this type could be frightening to 

women contemplating treatment, especially women coming from the streets or other diffi cult 

environments. To allay their fears, women were brought in for visits before they entered 

or committed to enter the residential treatment program. In these visits, the women had an 

opportunity to talk to counselors and other clients, return home, and revisit at will. Every effort 

was made to make them feel comfortable. The workers learned that it was best that women enter 

treatment on their own schedules and terms. 

Once in treatment, a woman maintained a relationship with her outreach worker, who usually 

conducted group sessions in the residential setting. The client decided when to move her primary 

therapeutic relationship from the outreach worker to the in-house counselor, and the outreach 

worker could withdraw gradually. If a woman did not wish to return to her home community 

following residential treatment, the outreach worker helped her settle into a new community 

(Melchior et al. 1999). 

Treatment Engagement, Placement, and Planning 91 
including outreach, needs assessment, planning 

and resource identification, service linkages, 

monitoring and ongoing reassessment, and 

client advocacy. In recent years, communities 

and agencies have shown considerable progress 

in developing formal linkages, protocols, 

and integrated care systems. To date, case 

management services are key to overseeing 

the appropriate referral and utilization of 

services. According to OAS (SAMHSA 2004), 

approximately 55 percent of facilities provide 

assistance with obtaining social services, 43 

percent provide assistance in locating housing, 

and 69 percent provide case management 

services. For an in-depth review, see TIP 

27 Comprehensive Case Management for 

Substance Abuse Treatment (CSAT 1998a). 

Research sheds light on the potential value of 

case management, in that it may be particularly 

useful for individuals with complex problems 

(Havens et al. 2007; Morgenstern et al. 2003). 

Morgenstern and colleagues (2006) completed 

a study on intensive case management with 

women receiving Temporary Assistance for 

Needy Families (TANF). The results show that 

women assigned to intensive case management 

had significantly higher levels of substance 

abuse treatment initiation, engagement, and 

retention in comparison to women who received 

only screening and referral. In addition, alcohol 

and drug abstinence rates were higher and 

length of abstinence was longer among women 

involved in case management. An earlier study 

showed similar results, emphasizing that women 

assigned to intensive case management accessed 

a greater variety of services (Jansson et al. 

2005). Improvement in abstinence rates and 

family and social functioning are also noted 

when case management services are employed 

(McLellan et al. 2003). 

Considerations in 

Treatment Placement and 

Planning 

Based on the assessment process, appropriate 

treatment placement for a client depends on 

many factors, including the nature and severity 

of a woman’s substance use disorder, the 

presence of co-occurring mental or physical 

illnesses or disabilities, and the identifi cation 

of other needs related to her current situation. 

Placement decisions are also affected by other 

psychosocial factors. Once the comprehensive 

assessment is completed, the placement can be 

determined. 

Women need to be able, whenever possible, 

to contribute to the planning and placement 

discussion for their treatment. For example, 

when residential care is recommended, barriers 

such as being unable to bring her children may 

cause a woman to reject the placement option. 

In this situation, it is critical to work with the 

woman to make appropriate arrangements to 

help her enter treatment. Treatment planning 

must also include assistance in helping her to 

express needs, make decisions and choices, 

and recognize that she is the expert on her life. 

Overall, active client involvement in all aspects 

of treatment planning signifi cantly contributes 

to recovery, validates and builds on a woman’s 

strengths, and models collaborative and mutual 

relationships, including, most importantly, the 

client–counselor relationship. 

To date, limited literature has examined 

placement criteria specific to women. However, 

some States have developed criteria for placing 

women in appropriate treatment options 

(CSAT 2007). The available State substance 

abuse treatment standards listed in Figure 5-3, 

Services Needed in Women’s Substance Abuse 

Treatment, should be considered in placing 

female clients in specifi c services. 

Levels of Care 

The need for appropriate level of care and 

treatment is not gender specific; both men and 

women require a range of treatment services at 

various levels of care. In 1991, ASAM developed 

patient placement criteria based on matching 

severity of symptoms and treatment needs with 

five levels of care. ASAM’s Patient Placement 

Criteria (ASAM’s PPC; ASAM 2001) identifi es 

six clinical dimensions: alcohol intoxication and/ 

92 Treatment Engagement, Placement, and Planning 
Figure 5-3 

Services Needed in Women’s Substance Abuse Treatment 

The following services are recommended by the consensus panel and reinforced by some State 

standards (CSAT 2007), and these services may be warranted across the continuum of care 

beginning with early intervention and extending to continuing care services. More than ever, 

services need to be tailored to women’s needs and to address the specific hardships they often 

encounter in engaging treatment services. Promising practices designed to treat women with 

substance use disorders include comprehensive and integrated clinical and community services 

that are ideally delivered at a one-stop location. Note: This list does not incorporate the 

customary services that are provided in standard substance abuse treatment, but rather services 

that are more reflective of women’s needs. 

Medical Services 

Gynecological care
 

Family planning
 

Prenatal care
 

Pediatric care
 

HIV/AIDS services
 

Treatment for infectious diseases, including viral hepatitis
 

Nicotine cessation treatment services
 

Health Promotion 

Nutritional counseling 

Educational services about reproductive health 

Wellness programs 

Education on sleep and dental hygiene 

Education about STDs and other infectious diseases; e.g., viral hepatitis and HIV/AIDS 

Preventive healthcare education 

Psychoeducation 

Sexuality education 

Assertiveness skills training 

Education on the effects of alcohol and other drugs on prenatal and child development 

Prenatal education 

Gender-Specifi c Needs 

Women-only programming; e.g., is the client likely to benefit more from a same-sex versus 

mix-gender program due to trauma history, pattern of withdrawal among men, and other 

issues? 

Lesbian services 

Cultural and Language Needs 

Culturally appropriate programming 

Availability of interpreter services or treatment services in native language 

Life Skills 

Money management and budgeting
 

Stress reduction and coping skills training
 

Treatment Engagement, Placement, and Planning 93 
Figure 5-3 

Services Needed in Women’s Substance Abuse Treatment (continued) 

Family and Child-Related Services 

Childcare services, including homework assistance in conjunction with outpatient services 

Children’s programming, including nurseries and preschool programs 

Family treatment services including psychoeducation surrounding addiction and its 

impact on family functioning 

Couples counseling and relationship enrichment recovery groups 

Parent/child services, including developmentally age-appropriate programs for children 

and education for mothers about child safety; parenting education; nutrition; children’s 

substance abuse prevention curriculum; and children’s mental health needs, including 

recreational activities, school, and other related activities 

Comprehensive Case Management 

Linkages to welfare system, employment opportunities, and housing 

Integration of stipulations from child welfare, TANF, probation and parole, and other 

systems 

Intensive case management, including case management for children 

Transportation services 

Domestic violence services, including referral to safe houses 

Legal services 

Assistance in establishing financial arrangements or accessing funding for treatment 

services 

Assistance in obtaining a GED or further education, career counseling, and vocational 

training, including job readiness training to prepare women to leave the program and 

support themselves and their families 

Assistance in locating appropriate housing in preparation for discharge, including 

referral to transitional living or supervised housing 

Mental Health Services 

Trauma-informed and trauma-specifi c services 

Eating disorder and nutrition services 

Services for other co-occurring disorders, including access to psychological and 

pharmacological treatments for mood and anxiety disorders 

Children’s mental health services 

Disability Services 

Resources for learning disability assessments
 

Accommodations for specifi c disabilities
 

Services to accommodate illiteracy
 

Services to accommodate women receiving methadone treatment
 

94 Treatment Engagement, Placement, and Planning 
Figure 5-3 

Services Needed in Women’s Substance Abuse Treatment (continued) 

Staff and Program Development 

Strong female role models in terms of both leadership and personal recovery 

Peer support 

Adequate staffing to meet added program demands 

Staff training and gender-competence in working with women 

Staff training and program development centered upon incorporating cultural and 

ethnic influences on parenting styles, attitudes toward discipline, children’s diet, level of 

parenting supervision, and adherence to medical treatment 

Flexible scheduling and staff coordination (Brown 2000) 

Adequate time for parent–child bonding and interactions 

Administrative commitment to addressing the unique needs of women in treatment 

Staff training and administrative policies to support the integration of treatment services 

with clients on methadone maintenance 

Culturally appropriate programming that matches specific socialization and cultural 

practices for women 

Source: Consensus Panel. 

or withdrawal potential; biomedical conditions 

and complications; emotional, behavioral, 

or cognitive conditions and complications; 

readiness to change; relapse, continued use 

or continued problem potential; and recovery 

environment. The levels of care are determined 

by the presence and severity of issues within 

each dimension. The current version (PPC-2R) 

lists five broad levels of care: 

• 	 Level 0.5: Early intervention 

• 	 Level I: Outpatient treatment/partial 

hospitalization 

• 	 Level II: Intensive outpatient treatment 

• 	 Level III: Residential/inpatient treatment 

• 	 Level IV: Medically managed intensive 

inpatient treatment (ASAM 2001) 

ASAM’s PPC-2R (2001) is used widely and 

standardizes treatment placement. It is focused 

on identifying individual treatment needs, but 

does not focus specifically on the placement 

of women or treatment needs that extend to 

children or family. Counselors needing detailed 

criteria for each level of care should consult 

ASAM’s PPC-2R Manual. The following review 

of ASAM’s levels of care contains information 

that is unique and important to women; it is 

not meant to be a comprehensive overview of 

ASAM’s placement criteria. When there are 

relevant issues, the specific needs of pregnant 

women and children are discussed at the end of 

each level of care. 

Early Intervention 

(ASAM Level 0.5) 

Early intervention, or ASAM Level 0.5, can be 

considered a pretreatment service that provides 

an opportunity for treatment providers to 

intervene across a wide variety of settings. It 

is designed for individuals with risk factors or 

problems associated with substance abuse but 

with whom an immediate substance-related 

disorder cannot be confirmed. Services that 

represent this level of care include assessment, 

psychoeducational services, and counseling. 

In essence, the goals for this level of care are 

prevention and intervention. For example, 

educational experiences allow clients to gain 

further awareness of their current substance 

Treatment Engagement, Placement, and Planning 95 
use and the expected consequences of this use, 

along with the future consequences of use if 

they continue on their present course. This 

level of care also provides a forum to assist 

individuals in developing skills associated with 

behavioral change, in creating strategies to 

avoid future problems related to substance use, 

and in establishing a supportive pretreatment 

environment and therapeutic alliance. 

Early intervention approaches can be provided 

through many channels—a drop-in model, 

in-home or mobile treatment services, or a 

pretreatment group in a treatment setting. It 

can also be provided 

through involuntary 

venues such as drug 

courts, or voluntary 

settings such as 

outpatient or primary 

medical care clinics.

Faith-based initiatives 

can also provide

opportunities for early 

interventions.

For women, early 

intervention services

appear quite valuable in 

enhancing motivation,

decreasing anxiety and 

reluctance in initiating

current and future 

treatment services, 

gaining support, and 

establishing strategies

to address obstacles 

associated with 

treatment access and 

engagement (Wechsberg 

et al. 2007). Programs

that provide fl exibility 

in attendance, easy

access to care, and 

at-home or mobile 

services are particularly conducive for women, 

especially those who have the primary role of 

parenting. TIP 34 Brief Interventions and Brief 

Therapies for Substance Abuse (CSAT 1999a), 

discusses how to implement brief interventions 

in substance abuse treatment and other settings. 

96 

Healthcare providers 

have a window 

of opportunity 

in working with 

women who abuse 

substances. Brief 

interventions can 

provide an opening 

to engage women 

in a process that 

may lead toward 	

treatment and 

wellness. 

Early intervention during 

pregnancy 

Pregnancy creates an increased sense of urgency 

for both clients and counselors because of the 

temporary upswing in motivation to change 

and the need for problem resolution. For some 

women who abuse substances, pregnancy creates 

a window of opportunity to enter treatment, 

become abstinent, quit smoking, eliminate 

risk-taking behaviors, and lead generally 

healthier lives (Hankin et al. 2000; Nardi 1998). 

Brief interventions are sometimes effective in 

helping pregnant women stop using substances 

(Hankin et al. 2000). Abstinence for pregnant 

women should be construed to include alcohol, 

tobacco, caffeine, and many over-the-counter 

medications, in addition to illicit substances. 

Some studies have found that brief interventions 

using motivational interviewing (MI) in prenatal 

care can reduce problem drinking by pregnant 

women (Handmaker and Wilbourne 2001; Miller 

2000). Therapists using MI employ a gentle, 

empathic style to avoid client defensiveness and 

constructively and compassionately explore 

ambivalence about change and motivation for 

recovery (refer to TIP 35 Enhancing Motivation 

for Change in Substance Abuse Treatment 

[CSAT 1999b]). MI may be more effective for 

those women who are primarily dependent 

on alcohol; studies targeting pregnant women 

identified as primarily abusing drugs have 

shown no differences between MI and other 

standard practices in reducing substance use 

(Winhusen et al. 2007). 

Detoxification (ASAM Levels I–IV) 

Detoxification is a set of procedures employed 

to manage acute intoxication and withdrawal 

symptoms from drug and alcohol dependence. 

During this process, the body’s physiology 

adjusts to the absence of alcohol or drugs. 

Detoxification alone is not substance abuse 

treatment; it is only the beginning of the 

treatment process. Issues such as retaining 

clients in detoxification, stabilization, and 

fostering treatment entry are discussed in 

TIP 45 Detoxification and Substance Abuse 

Treatment (CSAT 2006a). 

Treatment Engagement, Placement, and Planning 
Not all communities have detoxifi cation services. 

Furthermore, women’s programs do not often 

have adequate medical supervision to perform 

detoxification, hence women must be detoxifi ed 

at another facility. Typically detoxifi cation 

from alcohol or addictive drugs has been a 3- to 

5-day inpatient procedure, but as more and 

more health insurers have declined to reimburse 

inpatient detoxification, it increasingly is done 

on an outpatient basis. Yet, if severe withdrawal 

is expected (as from severe alcohol or sedativehypnotic dependence), detoxifi cation should 

be done in a medical facility. Withdrawal 

from severe alcohol use, sedatives, and 

benzodiazepines can have severe medical 

complications. 

Some women who are dependent on sedativehypnotics (tranquilizers) may need a 30-day 

withdrawal regimen with pharmacological 

medical intervention to prevent seizures. 

Concerning alcohol, more recent studies have 

begun to focus on the effects of sex-specifi c 

hormones in response to alcohol dependence and 

withdrawal. Although research on sex-specifi c 

hormonal differences in alcohol withdrawal is 

in its infancy, currently there appears to be a 

robust sex difference in seizure susceptibility, in 

that women appear to have less risk for alcohol 

withdrawal-induced seizures (Devaud et al. 

2006). Women also tend to display fewer and less 

severe alcohol withdrawal symptoms than men. 

However, even though research reflects less risk 

associated with withdrawal from alcohol among 

women, clinicians and health professionals 

need to maintain vigilance in evaluating 

withdrawal symptoms and other health 

concerns. Detoxification can be a vulnerable 

period for women who have a history of trauma 

and violence. They may have signifi cant 

distress associated with not feeling physically 

or psychologically safe, and anxiety associated 

with the anticipation of trying to manage 

their emotions and trauma-related symptoms 

without being able to self-medicate. From the 

outset of treatment, women need interventions 

and education surrounding traumatic stress 

reactions. Along with supportive and frequent 

contact with staff, trauma-informed services can 

help create or increase a sense of safety and a 

feeling of control. 

For all intents and purposes, if a woman’s 

contact with a substance abuse treatment agency 

stops at detoxification, the treatment system has 

failed. Women without treatment subsequent 

to detoxification are likely to relapse and be 

lost to followup. Thus, detoxifi cation programs 

should have adequate funding to include case 

management, brief interventions, and discharge 

planning. Immediately after detoxifi cation, 

a woman may be more likely to be ready for 

treatment, and this opportunity for engaging 

the woman in treatment should be maximized. 

Aggressive case management, referral networks, 

and treatment linkages are needed to prevent 

women from disengaging from treatment. From 

initial contact with the client, the ability to 

follow up, to coordinate care, and to provide 

comprehensive services (such as transportation 

and child care), is essential to effective 

treatment. 

Considerations for women who 

are parents with dependent 

children 

The safety of children often is a chief concern 

and one of the principal barriers to treatment 

engagement and retention for parents— 

especially women—entering detoxifi cation 

programs. Even if women do not have custody 

of their children, they often are the ones who 

continue to care for them. Thus, ensuring 

that children have a safe place to stay while 

their mothers are in detoxification is of vital 

importance. Working with parents to identify 

supportive family or friends may help identify 

available temporary child care resources. A 

consult or referral to the treatment facility’s 

social services while the patient is being 

detoxified is indicated when the care of children 

is uncertain (CSAT 2006). 

Detoxification and methadone 

treatment during pregnancy 

Some detoxification programs will not treat a 

pregnant woman because they lack the necessary 

obstetrical support and are concerned about 

liability. Detoxification presents critical risks to 

a fetus, and withdrawal of a pregnant woman 

from addictive drugs or alcohol should always 

Treatment Engagement, Placement, and Planning 97 
be accompanied by close medical supervision 

and monitoring. Risks of detoxifi cation depend 

on the drug being abused, but the primary drugs 

of concern are typically opioids and, potentially, 

sedative-hypnotics. Sudden withdrawal of 

these drugs results in withdrawal by a fetus 

and sometimes leads to fetal distress or death. 

Withdrawal should be done under supervised 

conditions and with proper substitutes, such as 

methadone for opioids. TIP 45 Detoxifi cation 

and Substance Abuse Treatment (CSAT 2006a), 

TIP 43 Medication-Assisted Treatment for 

Opioid Addiction in Opioid Treatment Programs 

(CSAT 2005b), and TIP 40 Clinical Guidelines 

for the Use of Buprenorphine in the Treatment 

of Opioid Addiction (CSAT 2004a), have more 

comprehensive information on this subject. 

In general, it is neither recommended nor 

necessary for pregnant women to cease 

methadone treatment. In situations where 

withdrawal is being contemplated, a thorough 

assessment should be conducted to determine 

whether the woman is an appropriate candidate 

for medical withdrawal. It is important to 

note that relapse rates among women who use 

heroin are high, thus placing their fetuses at 

risk for adverse consequences (Jones et al. 

2001). Situations in which medically supervised 

methadone withdrawal during pregnancy may 

be considered include the following: 

• 	The client moves to an area where methadone 

maintenance is not available. 

• 	The client has been stable during treatment 

and requests withdrawal before delivery. 

• 	The client refuses to be maintained on 

methadone. 

• 	The client plans to detoxify through a 

structured treatment program (Archie 1998; 

Kaltenbach et al. 1998). 

If withdrawal is elected, it should be conducted 

under the supervision of physicians experienced 

in perinatal addiction and under the guidance 

of a protocol using fetal monitoring. Medical 

withdrawal usually is conducted in the second 

trimester because of the danger of miscarriage 

in the first trimester and because withdrawalinduced stress may cause premature delivery 

or fetal death in the third trimester (Donaldson 

2000; Kaltenbach et al. 1998). While 

pharmaceutical agents other than methadone 

have been introduced to treat symptoms 

of opioid withdrawal, the research is still 

preliminary (Anderson et al. 1997; Dashe et 

al. 1998; Jones and Johnson 2001; McElhatton 

2001). 

Outpatient Treatment 

(ASAM Level I) 

Outpatient, or ASAM Level I, treatment usually 

consists of one or two weekly sessions of group 

or individual therapy. Outpatient treatment 

settings are the most common, are widely 

available, and are the setting in which most 

women receive treatment. In general, outpatient 

treatment is most appropriate for women with 

less severe substance use problems and with 

greater social support and resources. While 

outpatient services are used for less severe 

symptoms of substance use disorders, this level 

of treatment can be employed at various points 

across the continuum of care. Specifi cally, 

continuing care services use outpatient 

treatment to provide support for ongoing 

recovery and treatment in a less restrictive 

environment as recovery evolves. (Refer to 

chapter 8 for review of continuing care services.) 

Women who benefit most from outpatient therapy 

frequently have some stability in their lives, such 

as housing and employment. Effective outpatient 

treatment programs for women should be more 

comprehensive than traditional programs and 

should provide a constellation of services (refer 

to Figure 5-3). For example, outpatient services 

should evaluate the need for and provide child 

care and children’s treatment services. 

Although few women-only outpatient programs 

exist, mix-gender programs can be made more 

responsive to women’s needs by providing 

comprehensive case management, services, and 

programs that support more client-provider 

contact, more opportunities for individual 

therapy, and referral to other community 

services. The development of interagency 

relationships is essential, yet referral alone 

will not guarantee utilization of these services. 

Beyond staff support, it is often necessary to 

98 Treatment Engagement, Placement, and Planning 
initiate the first contact with the agency referral, 

to assist the client in developing or making the 

necessary arrangements to access the community 

service or referral, and to provide followup to 

obtain the outcome of the referral. Throughout 

the last two decades, substance abuse programs 

have acknowledged the necessity of establishing 

formalized relationships among community 

agencies to streamline services and to effectively 

address and manage the diverse needs of women 

seeking treatment for substance use disorders. 

TIP 46 Substance Abuse: Administrative 

Issues in Outpatient Treatment (CSAT 2006b), 

provides more information on this level of care. 

Intensive Outpatient Treatment 

(ASAM Level II) 

Intensive outpatient treatment (IOP), or ASAM 

Level II, provides a higher treatment level than 

traditional outpatient programs but does not 

require structured residential living. Generally, 

IOP provides many of the same services as 

residential treatment; however, the intensity 

of treatment, the time of engaging services, 

and level of counselor involvement are less. 

IOP appears to have higher completion rates 

than traditional outpatient services among 

postpartum women (Strantz and Welch 1995). 

The flexibility of IOP may help women overcome 

barriers to treatment, provided the program 

attends to the unique needs identifi ed during 

intake (refer to Figure 5-3). Although IOP 

historically provides more accommodating 

schedules and offers treatment during the 

evening, weekends, and other times of the day, 

it will not be as useful for some women unless 

child care and transportation are available. TIP 

47 Substance Abuse: Clinical Issues in Intensive 

Outpatient Treatment (CSAT 2006c), provides 

more information on this level of care. 

Residential and Inpatient 

Treatment (ASAM Level III) 

Residential treatment, or ASAM Level III, is for 

women who have multiple and complex needs 

and require a safe environment for stabilization, 

intensive treatment, and an intensive recovery 

support structure. Professional staff are 

available 24 hours a day, and the facility is 

clinically managed. The type of residential 

or inpatient placement depends in part on 

the severity and complexity of the woman’s 

conditions, including but not limited to cooccurring medical and psychiatric disorders, 

history of trauma (including sexual and domestic 

violence), and pregnancy. Clinical experience 

has shown that women in residential care 

frequently require some or all of the services 

listed in Figure 5-3 in addition to specifi c 

substance abuse treatment services. 

Residential treatment can take place in various 

settings, including halfway houses and other 

extended care facilities, primary residential or 

inpatient programs, and recovery homes. As an 

example, SHIELDS for Families (a Los Angeles 

agency) uses a combination of day treatment and 

housing to provide comprehensive residential 

treatment for families. Overall, the effectiveness 

of residential treatment appears to rely on at 

least one key element—length of treatment. 

Greenfield and colleagues (2004) reviewed data 

about the effectiveness of residential substance 

abuse treatment for women from CSAT’s 

Residential Women and Children/Pregnant and 

Postpartum Women (RWC/PPW) Cross-Site 

Study and two other national studies. Despite 

differences in treatment programs, client 

profiles, followup intervals, data collection 

methods, and other factors, all three studies 

found high treatment success rates—ranging 

from 68 to 71 percent abstinence—among 

women who spent 6 months or more in 

treatment. Success rates were lower for clients 

with shorter stays in treatment. 

While length of stay seems paramount, 

residential treatment has several other 

components that must be in place to meet the 

various roles, needs, and other presenting 

issues of women with substance use disorders. 

Whether short or long term, residential 

treatment must maintain a healing, nurturing, 

and safe environment. This may require special 

accommodations for women, particularly 

in mix-gender treatment centers. These 

accommodations include adequate facilities 

for visits with children, safety precautions, 

Treatment Engagement, Placement, and Planning 99 
and treatment programming and policies that 

decrease the likelihood of potential assaults and 

sexual involvement in mix-gender residential 

settings and women-only space. Women who are 

trauma survivors benefit from secure sleeping 

accommodations where they can maintain their 

sense of security and control over bedroom 

access (except staff rounds; Harris 1994). 

Children in residential treatment 

programs 

For many women, having their children with 

them in treatment is essential to their recovery 

and removes a barrier to treatment entry. 

Research suggests that allowing children to 

accompany their mothers to a residential 

program has a positive effect on engagement, 

retention, and recovery (Lungren et al. 2003; 

Szuster et al. 1996). For example, studies have 

found that length of stay in residential treatment 

is associated with women being able to bring 

their children with them (Hughes et al. 1995; 

Wobie et al. 1997). One study suggested that the 

earlier a mother’s infant resides with her in the 

treatment setting, the longer the mother’s stay 

in treatment will be (Wobie et al. 1997). Overall, 

women in residential treatment accompanied 

by their children showed better outcomes 

(abstinence, employment, child custody, and 

involvement with continuing care or support 

groups) than women not accompanied by their 

children at 6 months after discharge (Stevens 

and Patton 1998). Review Appendix B to 

obtain an overview of CSAT’s Comprehensive 

Substance Abuse Treatment Model for Women 

and Their Children. 

Since 2004, CSAT has funded over 50 grants 

to treatment facilities under its Residential 

Women and Children/ Pregnant and Postpartum 

Women (RWC/PPW) programs. This crosssite evaluation found that the 6- to 12-month 

treatment programs had several positive 

outcomes. First, alcohol and drug use was 

much lower 6 months after discharge compared 

with pretreatment. The percentage of women 

reporting alcohol use decreased from 65 

percent at pretreatment to 27 percent 6 months 

after discharge, and the percentage of women 

reporting crack/cocaine use decreased from 51 

to 20 percent. Second, 60 percent of the women 

reported being completely abstinent throughout 

the 6 months following discharge. Third, 

criminal involvement dropped markedly, and 

economic well-being improved. Next, pregnancy 

outcomes improved (fewer premature deliveries, 

fewer low-birth-weight babies, and lower infant 

mortality) compared with expected rates for 

this population. In addition, 75 percent of the 

women had custody of one or more children 

6 months after discharge, up from 54 percent 

before initiating treatment, and fewer clients 

had children in foster care (CSAT 2001a). 

Women who completed treatment that allowed 

children in residence had less psychological 

distress and improved skills for independent 

living, parenting, employment, and relationships 

(Saunders 1993). In fact, one study found 

that outcomes from a treatment environment 

that welcomed children were more positive 

for women both with and without children. 

Researchers suggest that “living with and 

helping with other women’s children may 

provide a sense of shared responsibility and 

community” in a therapeutic community 

(Wexler et al. 1998, p. 232). Chapter 7 addresses 

parenting and the need for children services; 

it also emphasizes the importance of providing 

assessment and treatment for both mothers and 

their children. 

The amount of responsibility the mother has 

for her children during her stay needs to 

be determined on an individual basis; some 

mothers can keep their children with them 

almost continually, whereas others may need 

to attend treatment apart from their children. 

Specifically, some women may not want the 

responsibility of parenting at such a stressful 

time in their lives but may feel social pressure to 

keep their children with them during treatment. 

These mothers should be supported in their 

decision to place their children in the care of 

others (such as reliable family members) during 

their treatment. The following questions can 

be used by agencies to determine some key 

decisions regarding children: 

• 	How will child care be handled if the mother 

is hospitalized? 

100 Treatment Engagement, Placement, and Planning 
• 	Are there limits on the severity of illness of 

mothers or children beyond which they will 

not be accepted by the program? 

• 	What rule infractions will result in expulsion 

from the program? 

• 	How will suspected child abuse or neglect be 

identified and reported? 

• 	 Does the program allow overnight home 

visits? What guidelines and rules need to be 

in place to permit mothers and their children 

to leave residential treatment overnight 

(Metsch et al. 1995)? 

• 	How will children be disciplined? 

• 	How will visitation by the mother’s partner 

be handled when court-ordered visitation 

privileges have been issued but the partner 

continues to abuse alcohol and/or drugs? 

Maintenance of relationships with noncustodial 

children is important. Reunifi cation with 

children in the care of child protective service 

agencies is a sensitive issue. Staff of residential 

programs should be knowledgeable about child 

welfare issues and develop collaborations with 

child protective services to facilitate an effective 

and supportive reunification process for mothers 

and children. 

Residential services for pregnant 

women 

Acknowledging the urgency of treating women 

who are pregnant, Federal law requires that 

pregnant women receive priority admission into 

substance abuse treatment programs, allowing 

them to bypass waiting lists and gain immediate 

admission when a bed in a residential program 

is available (42 U.S.C. § 300x-27[a]). The 

primary treatment provider must secure 

prenatal care if a pregnant woman is not 

already receiving such care. 

Notably, collaboration among providers of 

substance abuse treatment, obstetric care, and 

pediatric care is a necessity. A comprehensive 

care program for pregnant women that includes 

prenatal care and substance abuse treatment 

has been shown to improve birth outcomes 

and increase the chances of being drug free at 

delivery for women who used cocaine (Burkett 

et al. 1998). Corse and colleagues (1995) looked 

at innovative possibilities 

such as bringing 

primary obstetric care 

providers (usually 

a nurse practitioner 

or certifi ed nurse 

midwife) onsite. They 

found that educating 

nurse midwives about 

substance use disorders 

and pregnancy enhanced 

their effectiveness 

and level of comfort 

in working with this 

population. Foremost, 

residential staff should 

learn the danger signs of 

pregnancy complications 

and when to triage a 

woman to an emergency 

department or to the 

doctor of the woman’s 

choice. An internal 

or external medical 

or nursing resource is 

helpful to evaluate need 

for emergency care. 

Upon delivery, some 

infants have withdrawal symptoms that require 

supportive care. In individual cases, depending 

on symptom severity, babies may need to be 

managed pharmacologically, and most experts 

agree that newborns should remain hospitalized 

while on medication related to drug withdrawal. 

In a residential center, public health nursing 

visits are critical to the evaluation of infant and 

maternal status. If a program does not have a 

nursing staff, public health nurses can provide 

some service. 

The consensus panel recommends that 

residential programs provide a number of 

specialized services for pregnant women, 

including: 

• 	 Nutrition services 

• 	Prenatal care 

• 	Transportation to obstetric appointments 

• 	Childbirth education and preparation and a 

coach, if possible 

Telling Their 

Stories: Refl ections 

of the 11 Original 

Grantees That 

Piloted Residential 

Treatment for 

Women and Children 

for CSAT (CSAT 

2001c), provides 

profiles of residential 

programs for women 

and children, along 

with issues that 

arose in treatment 

and management, 

evaluation 

information, and 

lessons learned. 

Treatment Engagement, Placement, and Planning 101 
• 	 Mental health evaluation at least twice during 

the pregnancy and postpartum periods, and 

treatment as needed to rule out (or treat) 

postpartum depression or other disorders 

• 	Education about alcohol and drug use 

specifically related to pregnancy, including 

education about neonatal abstinence 

syndrome and, if possible, a tour of the 

delivery site’s nursery for the woman in 

anticipation of the need for infant monitoring 

in the hospital 

• 	Education about HIV/AIDS risk and 

management during pregnancy, especially 

because HIV/AIDS transmission to the fetus 

and infants can be prevented 

• 	Education about breastfeeding and strong 

support for mothers who nurse their babies 

unless they are HIV positive 

Comprehensive programs for women who are 

parents or pregnant typically include outreach, 

family support services, medical care, case 

management, and continuing care for women 

and their children (Finkelstein 1993, 1994). 

Some researchers recommend individual and 

group counseling services, independent living 

skills training, and parenting classes (Haskett 

et al. 1992). Childbirth education and family 

planning also are recommended for women 

in treatment at childbirth and postpartum, 

along with activities that address bonding 

and attachment. Home visits help in assessing 

a woman’s needs and in identifying family 

members who can support her in recovery 

(Grella 1996). Children who accompany 

their mothers to treatment can benefi t from 

separate, developmental- and age-appropriate 

programming, health care, and education 

programs including substance abuse prevention. 

For an overview of CSAT’s Comprehensive 

Substance Abuse Treatment Model for Women 

and Their Children, refer to Appendix B. 

Medically Managed Intensive 

Inpatient Treatment 

(ASAM Level IV) 

Treatment in a medically managed intensive 

inpatient setting, or ASAM Level IV, commonly 

is used for a person who is medically 

compromised and meets ASAM Level IV criteria. 

This patient is at high risk for complications 

associated with withdrawal and requires the full 

resources provided by a hospital. Typically, this 

type of acute inpatient treatment lasts between 

3 and 5 days; stays of 10 to 14 days are more 

likely in an acute care psychiatric unit. It most 

often includes medical detoxifi cation, client 

education, group therapy, individual therapy, 

family therapy, and medical treatment. 

As discussed in the detoxifi cation section, 

appropriate referral from inpatient care to 

subsequent long-term treatment is needed. 

Repeat assessments are performed to indicate 

when a client is ready for a less intrusive or 

less intense setting for treatment. This referral 

should include case management and linkage to 

other treatment services, community services, 

and support groups. 

Advice to Clinicians and Medical Staff: 

The Impact of Trauma and Prenatal Care 

Women who have been sexually traumatized may experience considerable emotional 

discomfort with prenatal care, labor, and delivery in part because of the necessity of 

frequent vaginal exams and the physical contact necessary to support women during 

labor and delivery. The optimal situation for many pregnant women with a history of 

sexual trauma is to have a female prenatal care provider or a female obstetrician. These 

clients should have a labor coach or a support person to accompany them on all medical 

visits and during the labor process and delivery. 

102 Treatment Engagement, Placement, and Planning 
In This
 

Chapter
 

Racially and 


Ethnically Diverse 


Women
 

Sexual Orientation 


and Women
 

Women in Later Life
 

Women in Rural 


America
 

Resources for Other 


Special Populations 


and Settings
 

6 Substance Abuse 

Among Specifi c 

Population Groups 


and Settings 

Overview 

Gender-appropriate and culturally responsive health care improves 

both short- and long-term outcomes, not just for women with 

substance use disorders but also for clients with almost any type of 

healthcare problem. The likelihood of good health or the prevalence 

of certain disorders is, in part, a product of gender. Certain health 

issues are unique to women; others affect women disproportionately 

compared to men; and still others have a different effect on women 

than on men. To add to these gender differences, the National 

Institutes of Health (NIH) has identified critical racial and ethnic 

disparities in health that result in different outcomes or consequences 

in some groups. Other factors such as sexual orientation also have 

been shown to affect health status (Dean et al. 2000). 

The risks of substance abuse, its consequences, and the processes for 

treatment and recovery also differ by gender, race, ethnicity, sexual 

orientation, age, and other factors. Women’s risks for substance use 

disorders are best understood in the context in which the infl uences 

of gender, race and ethnicity, culture, education, economic status, 

age, geographic location, sexual orientation, and other factors 

converge. Understanding group differences across segments of the 

women’s population is critical to designing and implementing effective 

substance abuse treatment programs for women. 

This chapter provides an overview of available substance-related 

research for women in specific racial and ethnic groups, settings, 

and special populations in the United States across four domains: 

demographics, substance abuse patterns, clinical treatment issues, 

and resiliency factors. It highlights the need for cultural competence 

in the delivery of substance abuse treatment and suggests specifi c 

and culturally congruent clinical, programmatic, and administrative 

strategies. For more detailed information on substance related 

Substance Abuse Among Specific Population Groups and Settings 103 
disorders and substance abuse treatment across 

racially and ethnically diverse populations; 

the influence of culture on substance abuse 

patterns, help-seeking behavior, and health 

beliefs; and guidelines for culturally congruent 

and competent treatment services, see the 

planned TIP Improving Cultural Competence 

in Substance Abuse Treatment (Center for 

Substance Abuse Treatment [CSAT] in 

development a). 

Main sections of this chapter address clinical 

issues related to treating women of different 

racial and ethnic groups, women of different 

sexual orientations, older women, and 

women living in rural areas. Although certain 

elements of their substance use disorders are 

common to all these groups (such as trauma 

and/or socioeconomic stresses), each group 

also has unique features that will further 

influence their engagement and successful 

completion of treatment (including cultural 

values, beliefs about health care, and helpseeking behavior). Each group of women also 

brings a unique capacity for resiliency and 

recovery, and these factors are explored as 

well. The chapter concludes with a brief review 

of special populations and settings—women 

with disabilities, women in the criminal justice 

system, and women who are homeless. 

Racially and Ethnically 

Diverse Women 

Hispanic/Latina Women 

Demographics 

Of the approximately 40 million Hispanic/ 

Latino people living in the United States and its 

Territories, Mexican Americans are the largest 

group (64 percent), followed by Puerto Ricans 

(10 percent), Central and South Americans 

(13 percent), Cubans (4 percent), and other 

Hispanics or Latinos (9 percent) (U.S. Census 

Bureau 2007). Half the U.S. Hispanic/Latino 

population is concentrated in California and 

Texas. An additional 23 percent reside in 

Florida, Illinois, New Jersey, Arizona, and New 

York (U.S. Census Bureau 2007). Women of 

Hispanic origin in the United States numbered 

17 million or slightly less than half the total 

U.S. Hispanic population (U.S. Census Bureau 

2001d). 

The Hispanic/Latino population is a young, 

rapidly growing ethnic and cultural group 

in the United States. At 14 percent of the 

population, Hispanics/Latinos currently are 

the largest ethnic subpopulation (U.S. Census 

Bureau 2007). The recent population growth of 

Hispanics/Latinos is mainly due to the relative 

youth and high birth rates of this population 

(Bachu and O’Connell 2001) and, in part, to 

immigration. Yet, most Hispanics/Latinos are 

born in the U.S. and are not immigrants (U.S. 

Census Bureau 2007). By 2050, Hispanics/ 

Latinos are expected to nearly triple in number 

(U.S. Census Bureau 2000b). 

The socioeconomic status of the U.S. Hispanic/ 

Latino population may reflect the circumstances 

of immigration; that is, those who immigrated 

for economic reasons (the vast majority) tend to 

be poorer, less well educated, and younger than 

the overall population. More than a quarter 

of all Hispanics/Latinos lack health insurance 

coverage for more than 1 year (Cohen et al. 

2004). Approximately 40 percent of Hispanic/ 

Latino families headed by women live in poverty 

(U.S. Census Bureau 2007), and many of these 

women are likely to face the combined stresses 

of poverty, lack of health insurance, and lack of 

health care (U.S. Census Bureau 2002). 

Substance use among Hispanics/ 

Latinas 

Alcohol 

Most research on substance abuse among 

Hispanics/Latinas has focused on alcohol (e.g., 

Ames and Mora 1988; Canino 1994; Gilbert 

1991) and has confirmed the widely held belief 

that, regardless of national origin, Hispanics/ 

Latinas generally have higher rates of abstinence 

from alcohol and drink alcohol less frequently 

than Hispanic/Latino men. In a survey of 

764 Hispanic/Latino men and 817 Hispanic/ 

Latina women of all ages, 33 percent of the 

104 Substance Abuse Among Specific Population Groups and Settings 
men reported frequent and/or heavy drinking, 

compared with 12 percent of the women. 

Conversely, 57 percent of the women versus 35 

percent of the men reported that they abstained 

from alcohol use. Thirty-one percent of the 

women reported infrequent drinking (AguirreMolina et al. 2001). This phenomenon has been 

attributed to strict cultural sanctions against 

drinking by women that are typical throughout 

Latin America (Mora 1998) and are maintained 

by many Hispanics/Latinas in the United States. 

Research indicates that some Hispanics/Latinas 

generally maintain the cultural norms of their 

countries of origin and resist social pressures to 

engage in substance use (Mora 2002). However, 

other research (e.g., Caetano 1988, 1989; 

Caetano et al. 2007) comparing substance abuse 

both by gender and within and across Hispanic/ 

Latino subgroups suggests a far more complex 

relationship between Hispanics/Latinas and 

substance abuse (Mora 2002). For instance, 

Mexican-American women show higher rates 

of abstinence than Cuban and Puerto Rican 

women. However, they also exhibit the highest 

rates of frequent heavy drinking of all Hispanic/ 

Latina subgroups (Caetano 1989; Mora 1998). 

Thus, Mexican-American women who consume 

any alcohol at all tend to drink frequently and 

heavily. Mora (1998) explains that this paradox 

originates from differences between immigrant 

Mexican women and their American-born 

counterparts. More established generations of 

U.S. Hispanics/Latinas—in particular young 

Mexican-American and Puerto Rican women— 

drink more alcohol than immigrant women of 

their subgroups. These differences in alcohol 

use among Hispanics/Latinas appear to depend 

primarily on age, generational status, level of 

acculturation, and country of origin (Collins and 

McNair 2002; Randolph et al. 1998). 

Illicit drug use 

The pattern of illicit drug use among Hispanics/ 

Latinas is influenced by level of acculturation 

and country of origin. In one study based on 

the Hispanic Health and Nutrition Examination 

Survey (HHANES) data, illicit drug use 

among Hispanics/Latinas generally increased 

with acculturation (Amaro et al. 1990). The 

2006 Treatment Episode Data Set (TEDS), a 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) data set that 

provides information on treatment completion, 

length of treatment stay, and discharge 

demographics, indicated that Hispanic/Latina 

women admitted to substance abuse treatment 

were more likely to report opiates (19 percent) 

as their primary substance of abuse followed 

by cocaine/crack (18 percent), marijuana (14 

percent), and methamphetamine. In addition, 

the primary substance of abuse varied according 

to Hispanic origin: Puerto Rican and CubanAmerican women reported more opiate use, 

whereas Mexican-American women reported 

more methamphetamine use (SAMHSA 2008). 

Sociodemographic factors 

associated with substance use and 

substance use disorders 

Socioeconomic status, age, and length of time in 

the United States are associated with substance 

use and substance use disorders among 

Hispanic/Latina women. Among this population, 

those with the most notable risks for substance 

use disorders are women who immigrated to 

the U.S. at an earlier age (before 7 years of 

age) or who were born in the U.S. (Canino 

et al. 2008; Vega et al. 2003). Of particular 

concern, the 2007 Youth Risk Behavior Survey 

found a growing prevalence of alcohol and 

other drug use among adolescent Hispanic/ 

Latina females (Eaton et al. 2008). Studies 

have also isolated employment, marital status, 

and educational level as predictors of alcohol 

consumption and substance use disorders 

among Hispanics/Latinas. In a study evaluating 

racial/ethnic differences among women with cooccurring mental and substance use disorders, 

Hispanic/Latina women possessed signifi cant 

social vulnerability characterized by lower 

socioeconomic and educational status, exposure 

to violent crimes, and higher rates of criminal 

justice involvement (Amaro et al. 2005). 

Gender socialization 

In the Hispanic/Latina culture, women often 

are afforded special status and respect as 

matriarchs of extended family networks (Mora 

Substance Abuse Among Specific Population Groups and Settings 105 
Advice to Clinicians and Administrators 

Substance Abuse Treatment and Hispanic/Latina Women 

Clinical: 

• 	 Conduct initial assessment to determine the women’s level of acculturation, 

development and identification of ethnic identity, and worldview (Baron 2000). 

• 	 Provide clients with opportunities to identify and express feelings about their heritage 

and self-perception. 

• 	 Encourage exploration of strengths in their cultural backgrounds, histories, and 

heritages, including opportunities to explore old and new ways to incorporate 

spirituality into their lives. 

• 	 Develop opportunities to build alliances and relationships with women (including 

staff and other clients) from other groups and cultures. 

Program Development: 

• 	 Generate a program philosophy that supports personal growth and empowerment 

within a cultural and family context. 

• 	 Develop linkages with other community resources and case management to help with 

legal issues, education, job training, domestic violence, medical care, housing, and 

other support systems. 

• 	 Plan for interpreter services and develop access to bilingual providers. 

• 	 Adopt acculturation assessment tools that include information on migration patterns, 

acculturation level, experiences, stress, country of origin, and specific endorsement of 

Hispanic/Latina values. 

• 	 Develop and provide psychoeducational family programs. 

Staff Training: 

• 	 Invest in culturally competent staff training that promotes an understanding of: 

− Common Hispanic/Latina cultural beliefs, worldview, customs, spirituality, and 

religion. 

− The possible relational needs of many Hispanics/Latinas. 

− The centrality of family and knowledge of approaches for incorporating family in 

treatment. 

− The immigration experience and effects of acculturative stress on many Hispanics/ 

Latinas’ roles, responsibilities, family life, substance abuse, and recovery. 

Source: Alvarez and Ruiz 2001; Caetano et al. 2007; CSAT 2003b; and Medina 2001 

2002). Some Hispanics/Latinas, especially those 

who are more acculturated, may deemphasize 

or reject these cultural expectations, but early 

childhood messages (e.g., the “proper role of a 

señorita”) may remain embedded in the cultural 

and personal identities of many in this group 

(Mora 1998). The stresses of negotiating and 

integrating traditional cultural expectations with 

new cultural values may result in or exacerbate 

the prevalence of mental and substance use 

disorders for many Hispanics/Latinas; more 

research is needed on this subject (Gloria and 

Peregoy 1996; Mora 1998). 

106 Substance Abuse Among Specific Population Groups and Settings 
Acculturation 

It has been suggested that acculturation, the 

process of adapting and adjusting to new 

surroundings while maintaining a cultural 

identity, more than any other factor, affects 

Hispanics/Latinas’ substance abuse (Caetano 

1989, 1994; Gilbert 1991; Keefe and Padilla 

1987; Markides et al. 1988). The onset of 

alcohol and drug abuse among some Hispanics/ 

Latinas may be explained by acculturative 

and environmental stresses (e.g., new roles, 

expectations, opportunities) that result 

in greater exposure to these substances 

(Gilbert 1991; Mora 1998). HHANES data 

study revealed that, for women of all ages in 

three major subgroups (Mexican American, 

Puerto Rican, and Cuban American), level of 

acculturation was correlated consistently with 

both increased frequency of consumption and 

increased probability of being a drinker at all 

(Black and Markides 1993). 

Studies consistently have shown that 

acculturation is positively correlated with 

consumption of greater quantities of alcohol, 

greater frequency of alcohol use, and higher 

rates of drug abuse among Hispanics/Latinas 

(Amaro et al. 1990; Mora 1998). These fi ndings 

have significant implications in providing 

substance abuse treatment, in that the role of 

acculturation and gender socialization should 

be a central theme in treatment planning. 

Specifically, Mora (1998) suggests that clinicians 

explore with Hispanic/Latina clients several 

key questions: How have their traditional roles 

changed since immigration or in comparison to 

their own mothers? How have these changes in 

roles influenced their substance use behavior? 

In what ways have educational and employment 

opportunities influenced or altered their 

substance use? 

Clinical treatment issues 

At first glance, the heterogeneity of Hispanics/ 

Latinas in terms of language, values, and 

backgrounds may seem to challenge the 

creation of effective, culturally responsive 

treatment programs for Hispanic/Latina women. 

Programs committed to serving Hispanics/ 

Latinas, however, can develop effective services 

by endorsing culturally competent practices, 

such as culturally specific assessment tools, 

counseling that endorses the clients’ worldviews, 

staff training to increase cultural awareness 

and knowledge, and programs that refl ect 

and respect cultural values. For example, 

substance abuse treatment programs can create 

a treatment environment that honors cultural 

heritage and incorporates values such as 

familismo (reliance on and regard for family and 

family cohesiveness), when appropriate. 

Some treatment issues reflect beliefs or 

traditions more specific to Hispanics/Latinas. 

A strong cultural prohibition exists against 

discussing family matters such as substance 

use or abuse during childhood, thus the 

use of psychoeducational groups to provide 

information on these topics may be more 

effective initially than therapy groups, where 

experiences are discussed openly. However, 

substance abuse counseling based on a family 

model often is well suited and is more culturally 

congruent for many Hispanics/Latinas. When 

engaging in family therapy, therapists need to 

enter the family relationship as a “learner,” 

since Hispanic/Latino families are so diverse. 

Counselors need to take the time to understand 

each client’s family history within a cultural 

context (Rotter and Casado 1998), including 

the initial identification of the country of origin 

and family members’ acculturation history 

and levels. Counselors also need to embrace a 

more expansive definition of family that may 

include extended family members and others. 

Early on in treatment, counselors need to assess 

how the current substance-related problems 

affect the family’s culture and how the culture 

affects the current presenting issues. Because 

the exalted role of motherhood in Hispanic/ 

Latino culture often makes loss of child custody 

especially stigmatizing, treatment programs 

need to provide support for appropriate family 

reunification. On a more fundamental level, 

Hispanics/Latinas may benefit from assistance in 

gaining English language skills, in job training 

that leads to employment, in fi nding stable 

housing, and in negotiating the requirements for 

treatment entry (Amaro et al. 1999; Kail and 

Elberth 2002). 

Substance Abuse Among Specific Population Groups and Settings 107 
Another treatment concern expressed among 

some Hispanics/Latinas in treatment— 

particularly those who are highly acculturated 

or isolated from a larger Hispanic/Latino 

community—is alienation from their cultural 

heritage. It may be difficult to address cultural 

alienation in treatment because a client may 

be far removed from her cultural background. 

A therapeutic decision must be made whether 

a cultural framework for recovery and 

empowerment should be utilized for all clients 

or only for those who request or show interest 

in this approach. Cultural knowledge can be 

empowering for many women of color, but 

not for all; care should be taken to adopt this 

approach only for those who are comfortable 

with it. 

Hispanics/Latinas represent 14 percent of all 

new HIV/AIDS cases among women (CDC 2007). 

Among Hispanic women, 65 percent acquired 

HIV/AIDS through high-risk heterosexual 

transmission and 33 percent were infected 

through injection drug use. Since Hispanic 

women represent the second largest ethnically 

diverse group of women living with HIV/AIDS at 

the end of 2005, education and other prevention 

services should be essential components of 

substance abuse treatment. 

Similar to other population groups of women, 

Hispanics/Latinas with substance use disorders 

experience a high rate of co-occurring mental 

disorders (Amaro et al. 2005). These disorders 

also need to be identified and treated if 

substance abuse treatment is to lead to recovery. 

A study of 66 Hispanics/Latinas enrolled in a 

residential substance abuse treatment program 

found that most (80 percent) reported a 

childhood history of abuse, as well as mental 

health problems (76 percent) and physical 

health problems (68 percent) (Amaro et al. 

1999). Compared with women who had not 

experienced childhood abuse, those with such 

a history experienced more severe health 

problems and were more likely both to lose 

custody of their children and to drop out of 

treatment. To treat these problems adequately, 

the relationship between a woman’s abuse 

history and substance use or co-occurring 

mental disorders must be determined. See TIP 

36 Substance Abuse Treatment for Persons With 

Child Abuse and Neglect Issues (CSAT 2000b) 

for more information. 

Resiliency factors 

The counselor should evaluate and adopt 

treatment approaches that are strength-based 

and that build on the resources and strengths 

of the client’s culture, individual traits and 

experiences, spirituality, and family. Among 

Hispanic/Latina clients, families are typically an 

important part of the support network and can 

function as a resource in recovery. Similarly, the 

centrality of family ties may provide motivation 

for treatment and a sense of responsibility to 

family. In a study that evaluated the role of 

family in reducing or delaying alcohol use among 

young Hispanic/Latina females, services that 

help improve parental connections can have 

long-term positive effects (Sale et al. 2005). 

In addition, culturally defined gender roles can 

also serve as a strength-based metaphor for 

the challenges that clients face as they begin 

their journeys in recovery. These gender roles, 

if properly acknowledged during treatment, 

can emphasize the most positive aspects of 

marianismo and hembrismo (the counterparts 

to machismo), such as “strength, perseverance, 

flexibility, and an ability to survive . . . [that 

can] . . . promote non-use while respecting 

Based on the knowledge and experience gained from the Demonstration Grant Program for 

Residential Women and their Children (RWC) and the Services Grant Program for Residential 

Treatment for Pregnant and Postpartum Women (PPW), the publication Lessons Learned: 

Residential Substance Abuse Treatment for Women and Their Children (CSAT 2003b) was 

developed. Along with other important aspects of residential treatment for women and children, 

this report provides insight into how to integrate culturally congruent services among Hispanic/ 

Latina women in residential substance abuse treatment. 

108 Substance Abuse Among Specific Population Groups and Settings 
“La Casita” (which means “the little house” in Spanish) is a residential chemical dependency 

treatment program designed to meet the needs of low-income Hispanic/Latina mothers. 

The treatment program places emphasis on the importance of family and its critical role in 

promoting therapeutic change. La Casita integrates culturally relevant strategies and Hispanic/ 

Latina cultural values with other effective treatment approaches, such as, “simpatia” (the 

promotion of pleasant social relationships), “lineality” (importance of authority fi gures in 

the solution of problems), and “reciprocity” (giving back, in some way, what was given). By 

adapting these cultural values in treatment, women have an opportunity to use their ethnic 

heritage as a catalyst for recovery (CSAT 2003b). 

and maintaining the role of the woman within 

the family” (Gloria and Peregoy 1996; p. 122). 

Similarly, religion and spiritual practices are 

very important for many traditional Hispanics/ 

Latinas in the United States and may serve as 

a source of sustenance in recovery. Religious 

beliefs may involve a combination of traditional 

practices and rituals, world religions, and 

religious practices in and outside the structure 

of church (Altarriba and Bauer 1998). 

African-American Women 

Demographics 

There are major differences in cultural 

identification, income, education, marital status, 

occupation, and lifestyle between AfricanAmerican women born in the United States 

and foreign-born women of African descent 

(Gray and Littlefield 2002; NIH, ORWH 1999). 

While this section focuses primarily on AfricanAmerican women born in the United States, 

further research is needed to identify intragroup 

variations in substance abuse etiology and 

effective treatments. 

More than 32 million African Americans live in 

the United States, including sizable numbers 

of both African and African-Caribbean 

immigrants. It is a relatively young population: 

32 percent of all African Americans are under 

age 18. More than half live in a central city 

within a metropolitan area. African Americans 

represent 12.3 percent of the U.S. population 

(U.S. Census Bureau 2001f). Nineteen million, 

or more than half, of all African Americans are 

females (U.S. Census Bureau 2001d). Among 

African-American women, poverty is more 

prevalent than in the general population (Gray 

and Littlefield 2002). Among African-American 

single mothers, approximately 35 percent live in 

poverty compared to 19 percent of non-Hispanic 

single white mothers. 

Although genetics account for differential rates 

of some diseases among African Americans 

(e.g., sickle cell anemia), biology alone 

explains very little about the disparities in 

health status between African Americans and 

Caucasians. Overall, African Americans have 

disproportionately higher rates of disease and 

illness, a wider variety of undetected diseases, 

more chronic health conditions, and shorter 

life expectancies than Caucasians. AfricanAmerican women experience higher morbidity 

and mortality rates than do Caucasian women 

for many health conditions (Minino et al. 2002). 

Substance use among African 

Americans 

Even though the total substance abuse 

admissions among African Americans has been 

steadily declining since the 1990s, TEDS reports 

that 21 percent of admissions to substance abuse 

treatment facilities were African American 

in 2006 in comparison to 12 percent of nonHispanic population (HHS 2008a). The primary 

source of referral to treatment among AfricanAmerican women was through self-referral or by 

family and friends (SAMHSA 2004). 

Alcohol 

According to TEDS (HHS 2008a), alcohol 

accounted for 25 percent of substance abuse 

treatment admissions among African-American 

women. While most research highlights 

differences in alcohol use patterns between 

African-American women and men, and between 

Substance Abuse Among Specific Population Groups and Settings 109 
African-American women and other diverse 

groups of women, little attention is given in 

reporting on the diversity of use among AfricanAmerican women within their cohort group 

and throughout their lifespan. In one study 

comparing differences in alcohol prevalence 

across age groups, ethnicity, and gender, 

prevalence rates among African-American 

females from 19 to 29 years of age rose from 

2 percent to 4 percent between 1992 and 2002 

(Grant et al. 2006). In a study evaluating the 

correlates of alcohol consumption of AfricanAmerican women, women age 40 to 49 have 

shown the highest prevalence of alcohol 

consumption (Rosenberg et al. 2002). 

Illicit drug use 

Among African-American women, most 

admissions to treatment facilities were for 

cocaine/crack abuse (35 percent; HHS 2008a). 

From the same data set, opioids, primarily 

heroin, accounted for 18 percent of substancerelated admissions. In a study that focused 

on severity of alcohol use and crack/cocaine, 

evidence suggests that as the level of alcohol 

consumption increases among African-American 

women, the severity of symptoms associated 

with comorbid mental disorders, sexual risk 

behaviors, and consumption of crack/cocaine 

increases significantly (Zule et al. 2002). Among 

African Americans identified as individuals 

who use crack-cocaine, more than 70 percent 

reported concerns regarding food, clothing, 

and transportation, and approximately 50 

percent reported problems associated with 

shelter, medical issues, and employment (Zule 

et al. 2003). With less adequate housing, 

financial resources, medical care, and higher 

cumulative stress, African-American women 

face an increased susceptibility to substance use 

disorders and other health conditions. 

Clinical treatment issues 

Beginning in the 1990s, research on AfricanAmerican women with substance use disorders 

focused on low-income, urban women who 

were dependent on cocaine (Roberts et al. 

2000). Now, literature on substance abuse and 

treatment among African-American women 

has expanded and environmental stressors 

have been examined, including psychosocial, 

sociodemographic, and economic disparities. 

While research remains limited in the area of 

treatment approaches and strategies, literature 

is beginning to reflect promising practices for 

African-American women. 

From the outset, it is vital that AfricanAmerican women have access to services that 

provide social support during their pursuit 

of recovery. Research suggests that AfricanAmerican women are at risk for substance abuse 

due to the level of exposure to biopsychosocial 

and economic stressors and the subsequent 

difficulty in coping with these life circumstances 

(Gray and Littlefield 2002). They often 

experience greater emotional distress and 

more relationship problems (Liepman et al. 

1993; Henderson 1994). Similar to all groups 

of women, African Americans have very high 

rates of trauma and abuse, so treatment needs to 

utilize trauma-informed services. 

Coupled with direct and indirect effects of 

historical trauma (including a history of slavery, 

lynchings, and racism) (Barnes-Josiah 2004), 

African-American women disproportionately 

experience negative health and social 

consequences of alcohol and drug use (Boyd 

et al. 2006). For example, African-American 

women are more likely to have their children 

legally removed from their custody, in part, 

as a result of societal bias and discrimination 

(Wallace 1990). Additionally African-American 

women are 10 times more likely than Caucasian 

women to have positive drug screens. Yet, 

this difference may be directly related to a 

disproportionate percentage of testing among 

African-American women (Neuspiel 1996). 

Subsequently, this threat of loss of child custody 

or legal sanctions for drug use during pregnancy 

may prevent African-American women from 

obtaining prenatal care or seeking substance 

abuse treatment. Nonetheless, once treatment 

is initiated, issues surrounding pregnancy, child 

care, parenting, and custody need be addressed 

in a nonthreatening but constructive manner–– 

showing support and guidance in promoting and 

nourishing a healthy parent–child relationship. 

110 Substance Abuse Among Specific Population Groups and Settings 
Other health consequences include a higher 

risk for developing alcohol-related disorders, 

including liver cirrhosis, and a greater 

propensity to experience toxic effects of cocaine 

that may lead to earlier onset or greater risk for 

health problems, particularly cardiovascular 

disease (D’Avanzo et al. 2001). According to the 

HIV/AIDS Surveillance Report (CDC 2007), 

African-American women are 23 times as likely 

to be diagnosed with HIV/AIDS in comparison 

to white women, and 4 times more likely than 

Hispanic women. Among African-American 

women with HIV/AIDS, 74 percent acquired 

HIV/AIDS through high-risk heterosexual 

transmission and 24 percent were infected with 

HIV through injection drug use. To effectively 

address pertinent health and clinical issues, 

treatment programs also need to incorporate 

HIV/AIDS prevention, intervention, and 

treatment services. 

Coupled with these risk factors, there is a 

common myth that African-American women 

“can withstand any amount of pain and keep 

on working” (McGee et al. 1985; p. 7). This 

myth may have significant consequences for 

African-American women who have substance 

use disorders––delaying treatment, sacrifi cing 

self to care for others, and negating the need 

for preventive health care and substance abuse 

treatment. (For further review of roles and 

expectations of African-American women, see 

Reid 2000.) 

Once in treatment, African-American women 

need a gender-responsive, strengths-based 

model to develop or enhance a sense of 

empowerment by recognizing their assets 

and history of fortitude (Roberts et al. 2000; 

p. 905). This model provides a framework 

whereby treatment shifts the focus away from 

individual internal deficits. For AfricanAmerican women with substance use disorders, 

treatment approaches need to extend beyond 

the general parameters of gender-responsive 

treatment to include interventions that focus on 

social contexts across multisystems including 

social networks or groups, family involvement 

and therapy, and community involvement and 

interventions (Boyd-Franklin 1989; Bell 2002). 

Likewise, spiritual components and Afrocentric 

perspectives need to be incorporated into 

treatment to ensure a holistic approach and 

to assist African-American women in recovery 

(Brome et al. 2000; Rhodes and Johnson 1997; 

Roberts et al. 2000). 

Role of spirituality and faithbased recovery 

Although there is no “one size fits all” defi nition 

of spirituality, spiritual activities nevertheless 

offer women in recovery an outlet to express 

problems, seek guidance from others or from 

a higher power, and move from disharmony to 

harmony with self and others without fear of 

repercussion, shame, or punitive actions (Brome 

et al. 2000). America has an extensive history 

of religious movements and spiritually led 

programs that address substance abuse (White 

and Whiters 2005). Today, there is more focus 

on the importance of integrating these faithbased approaches into addiction treatment, 

and more recognition that African-American 

churches can be a vital recovery tool. 

Spirituality has been an important source of 

support for many African-American women 

(Lewis 2004). Historically, spirituality and 

religion have provided a central organizing 

framework for self-defi nition, problemsolving, 

and connection to self and others, especially 

among African-American women. Black 

churches have led the promotion of health care, 

disease prevention, and psychological well-being 

(Leong 2006). Overall, women in recovery from 

substance use disorders who express high levels 

of spirituality demonstrate a more positive selfconcept, better attitude toward parenting and 

perception of family climate, more active coping 

style, and greater satisfaction with their social 

support than women who are in recovery but 

expressed lower levels of spirituality (Brome et 

al. 2000). Notably, treatment providers need to 

understand how African-American women relate 

to traditional religion and spirituality and how 

that relates to positive mental health outcomes. 

For an overview of spirituality and religion and 

its implications for psychotherapy with AfricanAmerican families, refer to Boyd-Franklin and 

Lockwood 2009. 

Substance Abuse Among Specific Population Groups and Settings 111 
Role of an Afrocentric perspective 

Though it is important not to make the 

assumption that all African-American women 

want to identify with a particular African 

tradition, acknowledgment of the richness of 

the African-American heritage or adoption of 

an Afrocentric perspective is another crucial 

component of a culturally and gender-responsive 

treatment program for many African-American 

women. As an example, The Iwo San Program, 

located in Cleveland, Ohio, incorporated an 

Afrocentric component in treatment, along 

with cognitive–behavioral therapy and an 

Afrocentric approach to the 12-Step program, 

with a primary goal of increasing the women’s 

understanding of what it means to be African 

American and of promoting self-pride through 

embracing African ancestry, history, and culture 

(CSAT 2003b). Women learned and used the 

“Seven Principles” from the Swahili tradition 

and community as a guide for daily living. (For 

review, see text box below.) 

The concepts of empowerment, the positive role 

of African-American women in the family and 

larger community, and the ability to build on 

their inherent strengths in the face of adversity 

are important to culturally responsive treatment 

(Rhodes and Johnson 1997). By incorporating 

an Afrocentric worldview in substance abuse 

treatment, African-American women will likely 

benefit from this critical protective factor 

in enhancing self-image, self-esteem, and 

centeredness in recovery (Roberts et al. 2000). 

Role of group, cognitive– 

behavioral, and family therapy 

Group therapy and adapted cognitive– 

behavioral therapy (CBT) show promise when 

grounded in the African-American worldview 

(Brown et al. 1995; Holcomb-McCoy 2004; 

Washington and Moxley 2003). By placing 

emphasis on the importance of community, 

group therapy can be a powerful and culturally 

appropriate approach that provides a 

supportive recovery environment and acts as 

a buffer to stressors associated with recovery. 

In essence, it is an opportunity to reinforce or 

rebuild a community connection that supports 

health. (Refer to Figure 6-1 for a review of 

promising practices and strategies.) 

CBT may be a noteworthy substance abuse 

treatment approach if adapted to fit the AfricanAmerican worldview. Yet, minimal research 

has been carried out on the effectiveness of 

CBT and substance use disorders. Between 

1950 and 2006, only 12 studies have examined 

CBT among ethnically diverse populations, 

with only one study focused on substance abuse 

and CBT (Horrell 2008). While this one study 

suggests effectiveness with CBT (as measured 

by reduction in frequency and amount of drug 

Nguzo Saba: The Seven Principles 

Umoja (Unity) 

Kujichagulia (Self-Determination) 

Ujima (Collective Work and Responsibility) 

Ujamaa (Cooperative Economics) 

Nia (Purpose) 

Kuumba (Creativity) 

Imani (Faith) 

Source: Karenga 1998. Note: These seven principles are associated with each day of 

celebration of Kwanzaa. 

112 Substance Abuse Among Specific Population Groups and Settings 
Figure 6-1 

Group Therapy: Promising Practices and Strategies for 

African-American Women 

• 	 Endorse group work to promote values of strong kinship and emphasis on community. 

• 	 Promote cohesiveness through closed group formats (same group members from start to 

fi nish). 

• 	If feasible, limit group participation to African-American women to enhance safety and 

comfort. 

• 	 Use meditative, spiritual, and experiential exercises to build upon internal strengths. 

• 	 Use opening and closing rituals, including a termination ritual at the end of the group. 

• 	Incorporate African ancestry and cultural practices. 

• 	 Adapt language to involve recovery in context of family and community. 

• 	 Adopt culturally specific content in treatment modules including themes surrounding 

relationships, spirituality, family, ethnic, and cultural identity. 

• 	 Draw upon African-American history as a foundation of recovery, using examples from the 

work of artists, writers, musicians, heroes, spiritual and political leaders, etc. 

Sources: CSAT 2003b; Holcomb-McCoy 2004; Kohn et al. 2002. 

use among African-American clients), the 

results need to be cautiously interpreted due to 

a high participant dropout rate. To date, more 

research is needed to examine the effectiveness 

of CBT with ethnically diverse adult populations 

with substance use disorders. While research 

is limited, there is emerging evidence that CBT 

can be a helpful approach among AfricanAmerican clients. Kelly (2006) states that 

CBT may offer African-American women an 

opportunity of empowerment, supported by a 

nonjudgmental and collaborative therapeutic 

relationship, and centered on skill and support 

system development. It can be easily adapted to 

match a strength-based approach rather than a 

deficit model. To help decrease the Eurocentric 

bias in CBT, clinicians should avoid projecting 

or overemphasizing the value of cognition 

without incorporating the relevance of emotional 

expression and spirituality. As important, CBT 

should recognize and emphasize the importance 

of family and community support as an integral 

part of recovery. 

Regardless of approach, treatment should 

evolve around the premise that family and 

community are essential elements to healing and 

recovery. Treatment programs and counselors 

can endorse these values within the program by 

using mentors from the community for women 

in early stages of recovery (Stahler et al. 2005). 

Overall, more attention is needed to involve and 

incorporate a multisystems framework including 

a family systems approach in treatment. Family 

therapy is characteristically a more pertinent 

mode of therapy for African-American women 

(Boyd-Franklin 1989). 

Resiliency factors 

Consistent with earlier work (Hill 1972), Gary 

and Littlefield (1998, p. 99) identifi ed the 

following resiliency factors in their study of 

African-American families: 

• 	A high degree of religious or spiritual 

orientation (as evidenced by church 

membership, church attendance, a sense of 

right and wrong, teaching moral values, and 

a shared religious core) 

• 	A sense of racial pride (telling their children 

about Black history, discussing racism in 

one’s family, telling children what it is like to 

be African American, preference for being 

identified as an African American) 

Substance Abuse Among Specific Population Groups and Settings 113 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and African-American Women 

Clinical: 

• 	 Incorporate a strengths-based approach versus reliance on a traditional defi cit model. 

• 	 Use an Afrocentric perspective, when appropriate and welcomed, to provide a 

framework for recovery. 

• 	 Involve family members and community to build a network of safety and support. 

• 	 Recognize the relevance of spirituality with the client, and encourage involvement to 

enhance or secure recovery. 

Program Development: 

• 	 Use elements of the African-American heritage or adopt an Afrocentric perspective to 

provide a more culturally responsive treatment program. 

• 	 Create program policies and procedures that support rather than limit family and 

community involvement. 

• 	 Develop treatment strategies that strengthen a sense of community within the 

treatment program, and create avenues to broaden this sense of community beyond 

the program; i.e., providing outreach activities or inviting community members to 

treatment graduation exercises. 

• 	 Invest in workforce development for African-American staff. 

Staff Training: 

• 	 Provide culturally competent staff trainings promoting an understanding of— 

− African-American history and heritage. 

− The role of racism and discrimination in stress-related health issues and substance 

abuse. 

− The potential role and importance of spirituality in recovery. 

− Various African traditions and beliefs, and the knowledge of resources to support 

an Afrocentric perspective with the client. 

− The value and necessity of outreach services to the African-American community. 

• 	 A strong achievement orientation (high 

expectations for achievement and attainment, 

goal directedness, etc.) 

• 	 Resourcefulness (possessing personal talents 

and skills, self-reliance, self-suffi ciency, 

independence, and the ability to cope with 

crises) 

• 	 Family unity (possessing a sense of 

cohesiveness, family pride, family 

togetherness, and commitment; i.e., the 

family comes fi rst) 

• 	 Display of love and acceptance (the ability 

to affirm one another and to respect, 

appreciate, and trust one another) 

• 	 An adaptability of family roles (having 

role flexibility, sharing responsibility, and 

communicating with one another) 

• 	 A strong kinship bond (e.g., a high degree of 

commitment to the family, a feeling of mutual 

obligation, kin interaction, and support) 

• 	 Community involvement (service to others 

and membership and active involvement in 

community organizations) 

114 Substance Abuse Among Specific Population Groups and Settings 
Asian- and Pacifi c-American 

Women 

Demographics 

Asian origins can be traced to many countries, 

including Cambodia, China, India, Japan, 

Korea, Laos, the Philippines, Vietnam, and 

others. By some counts, the number of national 

and ethnic groups is nearly 50, representing 

more than 60 primary languages (Barnes and 

Bennett 2002; Grieco 2001; New York State 

Education Department 1997). The three largest 

groups of Pacific Islanders are Hawaiians, 

Guamanians or Chamorros, and Samoans 

(from the Mariana Islands, of which Guam 

is the largest). In all, 24 different groups are 

considered Pacific Islander, and individuals 

from many of these groups have migrated to the 

United States. More than half of U.S. residents 

who are Pacific Islanders live in California and 

Hawaii (Grieco 2001). Yet, over the past few 

decades, the Asian-American and Pacifi c-Island 

populations have become increasingly dispersed 

across the United States (U.S. Census Bureau 

2001f). 

Asian and Pacific Americans are a rapidly 

growing group, increasing by more than 7 

million over the last 20 years (U.S. Census 

Bureau 2001c). According to the 2002 Census, 

Asian and Pacific Americans constitute about 

4.4 percent of the total U.S. population (12.5 

million individuals), of whom slightly more than 

half (51.6 percent) are women (U.S. Census 

Bureau 2001d). Asian- and Pacifi c-American 

women represent 13 percent of all women of 

color (U.S. Census Bureau 2001d). They are a 

relatively young group with 25 percent under 

age 18. Asian and Pacific Americans are both 

more likely to occupy one or the other end 

of the continuum in educational and income 

levels––either obtaining the highest educational 

and income levels or experiencing considerable 

poverty and a lack of education in comparison 

to non-Hispanic whites (Reeves and Bennett 

2003). 

Substance abuse among Asian 

and Pacifi c Americans 

Although Asian and Pacifi c Americans 

constitute about 4 percent of the population, 

they represent less than 1 percent of admissions 

to substance abuse treatment facilities in 

1999. However, this represents an increase in 

treatment admissions of 37 percent from 1994 to 

1999 among this population (SAMHSA 2004). 

Alcohol 

In comparison to other ethnic groups, this 

population has the lowest percentage of 

current drinking history and of past year 

alcohol dependence or abuse (SAMHSA 2006). 

According to the results from SAMHSA’s 2006 

National Survey on Drug Use and Health 

(NSDUH; SAMHSA 2007), the rate of binge 

alcohol use was also the lowest among Asian 

Americans. Of the 3,951 Asian- and Pacifi cAmerican women admitted for substance abuse 

treatment in 1999, 27 percent of admissions were 

for alcohol abuse, a relatively low proportion 

(SAMHSA 2004). 

Lower percentages of alcohol intake may be, 

in part, a result of the genetic disposition of 

the “flushing” response among Asians (Collins 

and McNair 2002). More than 25 percent of 

Asians possess a gene that causes a slower 

metabolism of normal oxidation of acetaldehyde. 

With elevated levels of acetaldehyde in the 

blood, individuals may experience a range 

of physical reactions including perspiration, 

heart palpitations and tachycardia, nausea, 

headaches, and facial fl ushing. Individual 

reactions can vary in intensity and time of onset, 

which also contributes to the amount of alcohol 

consumed (Weatherspoon et al. 2001). 

Alcohol patterns are largely influenced by the 

norms established within Asian communities 

in the United States, or by the cultural norms 

established in the country of origin. The low 

drinking rates among women of all Asian- and 

Pacific-American groups seem to derive in part 

from the large numbers of abstainers among 

the foreign-born population. Those born in 

the United States are more likely to use alcohol 

and tobacco. Various studies have shown that 

Substance Abuse Among Specific Population Groups and Settings 115 
educated, young, middle-aged Asian-American 

women, with higher levels of acculturation, are 

more likely to drink than other subpopulations 

of Asian-American women (Gilbert and Collins 

1997; Towle 1988). Among Asian-American 

groups of recent immigrant status, it is more 

difficult to determine specific substance abuse 

and dependence patterns. In addition, recent 

immigrants are less likely to seek treatment and 

less able to access treatment services; therefore, 

they are not as likely to be represented when 

assessing prevalence. 

Regarding cultural norms, solitary drinking 

practices generally are discouraged and 

often carry significant consequences. Among 

recent and other fi rst-generation immigrants, 

the importance of maintaining face, coupled 

with insufficient understanding of substance 

use–related problems, can result in denial of 

substance abuse problems, family sanctioning, 

or collusion in substance abuse–related 

behaviors if drinking practices exceed cultural 

practices and expectations (Chang 2000). 

According to the TEDS (SAMHSA 2006), 26 

percent of Asian and Pacific Americans identify 

alcohol as their primary drug of choice upon 

treatment admission. 

Illicit drug use 

The rates of illicit drug use are relatively 

low among Asian- and Pacifi c-American 

women compared with other racial and ethnic 

groups. Currently, methamphetamine (33 

percent) bypasses alcohol as the primary drug 

Advice to Clinicians and Administrators: 

Substance Abuse Treatment and Asian- and Pacifi c-American Women 

Note: Minimal treatment research is available pertaining to substance abuse treatment among Asianand Pacific-American women. Therefore, information was gathered using literature across various 

modalities in behavioral health to help support the following recommendations. 

Clinical: 

• 	 Address the importance of ethnic heritage and assess the level of acculturation in 

the beginning of treatment in order to avoid making assumptions regarding cultural 

values, family structure, gender roles, and styles of communication. 

• 	 Incorporate drug and alcohol education in order to reduce the stigma attached to 

substance abuse and dependence. 

• 	 Approach treatment from the vantage point of promoting overall health rather than 

focusing solely on substance abuse; include a holistic connection between body, mind, 

and spirit. There is value in reframing the presenting problem by placing emphasis on 

the positive aspects for change. 

• 	 Provide a nurturing environment that does not encourage cultural and gender-related 

tendencies toward self-blame (Kitano and Louie 2002). 

• 	 Develop trust and build a therapeutic alliance to help decrease internalized feelings of 

guilt and shame. 

• 	 Honor the importance of family as the focal point, and that maintaining family honor, 

obligations, and responsibilities are central to women. 

• 	 Focus on problemsolving, goal-oriented, and symptom-reduction strategies to 

circumvent the likely shame associated with delving into past alcohol or drug use 

behavior. 

• 	 Explore the history of trauma and the potential for posttraumatic stress symptoms and 

disorder. Many older immigrant Asian-American women have been exposed to losses, 

torture, and other types of war-related trauma. 

116 Substance Abuse Among Specific Population Groups and Settings 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and 

Asian- and Pacific-American Women (continued) 

Program Development: 

• Use a psychoeducational model as an integral ingredient in treatment.

• Consider the appropriateness of home visits to engage families from the outset prior

to individual treatment services. 

• Incorporate native language services or community resources, e.g., interpreter

services. 

• Provide separate treatment groups for women to reduce restrictions imposed by

gender role expectations. 

• Develop a psychoeducational family treatment program to support the individual in

relation to her family and to provide education regarding addiction. 

• Implement a lecture series that addresses both Western and traditional concepts of 

disease and treatment. 

• Consider the adaptation of a peer-to-peer support group to establish or support 

culturally appropriate individual and community supports for recovery. 

Staff Training: 

• Provide culturally competent staff training to promote an understanding: 

• Of the diversity of Asian- and Pacific-American women and of the relevance of 

cultural, language, and socioeconomic barriers. 

− Of the role of acculturation in alcohol and drug use practices.

− That reporting substance abuse problems can be a significant source of shame for 

women and her family, and can be perceived as hurtful toward family. 

− Of the importance of “otherness” and the relevance of community and family in

the perception of self-identity as a women. 

− That family is central, along with the maintenance of family obligations.

− That individuals with socially stigmatized behaviors, such as drug abuse, may

experience significant consequences from their family and community. 

− That traditional gender roles are often restrictive and influenced by generational 

and acculturation levels. 

− That communication is more likely to follow a hierarchy pattern whereby elders

are respected. 

Sources: Chang 2000; Kitano and Louie 2002; McGoldrick et al. 1996; Torsch and Xuequin 2000. 

of abuse upon treatment admission. After 

methamphetamine, the most frequent cause 

of admission for illicit drug use among AsianAmerican women is marijuana (16 percent), 

followed by opioids (11 percent), and cocaine/ 

crack (11 percent) (HHS 2008a). Yet, variations 

exist across subpopulations in drug and alcohol 

patterns. 

Clinical treatment issues 

Foremost, treatment providers need to 

understand, acknowledge, and incorporate 

cultural values within the treatment process. 

The family is the center of most Asian and 

Pacific Island cultures and is an important 

consideration for effective treatment for 

women. The definition of family is expansive 

Substance Abuse Among Specific Population Groups and Settings 117 
“Acculturation... 

refers to the manner 	

in which individuals 

negotiate two or 

more cultures 

where one culture is 

considered dominant 

while the other 

culture is perceived 

to have less cultural 

value” (Leong et al. 	

2007, p. 424). 

and includes not only 

immediate and extended

family members 

determined by blood 

and marriage, but also

other members of the 

community. Among 

women, family ties,

loyalties, cultural

expectations, and 

beliefs can serve as a

protective factor against

substance abuse (Joe 

1996). Moreover, the 

concept and value of

interrelatedness among 

family, community, 


environment, and


the spiritual world is 

essential in many Asian 

and Pacifi c Island 

cultures, and these tenets should be woven 

throughout the treatment program and clinical 

services (for an overview of treating Asian- and 

Pacific-American clients and their families, refer 

to Chang 2000). 

More than 65 percent of the Asian-American 

population is foreign-born (U.S. Census Bureau 

2004). Thus, stress specific to immigration 

and acculturation is more likely. This has 

significant implications for treatment planning 

and services in a variety of ways, particularly 

in accessing and addressing acculturation stress 

and its relationship to substance use and other 

psychological symptoms, specifi cally depression 

(Chen et al. 2003). 

A complex set of barriers to care can discourage 

Asian- and Pacific-American women from 

availing themselves of substance abuse treatment 

and other health care. Asian-American women 

who do not speak English or whose cultural 

traditions include a sense of shame for ill health 

often do not seek medical care (Leigh 2006). The 

problem is compounded by the unsurprising 

denial of substance abuse in a climate that 

favors family ties, a reverence for authority, and 

the dearth of culturally responsive substance 

abuse treatment services (Kitano and Louie 

2002, p. 352). In addition, women typically 

assume the role of primary caretaker, holding 

the essential responsibility of nurturing and 

supporting the family, even at the expense of 

individual health concerns. 

The development of empirically supported 

methods is evolving, yet research relevant to 

specific treatment needs among Asian- and 

Pacific-American women is sparse. Borrowing 

from the field of cross-cultural psychotherapy 

(Chang 2000; Leong and Lee 2006), treatment 

requires thorough assessment that includes such 

factors as circumstances of immigration, degree 

of assimilation, ethnic background, and health 

beliefs. The Asian American Multidimensional 

Acculturation Scale shows considerable promise 

in assessing women’s multidimensional levels of 

acculturation (Chung et al. 2004). It provides a 

more comprehensive assessment of acculturation 

and its effect on psychological functioning. 

Although outcome research specific to Asianand Pacific-American women in substance abuse 

treatment is lacking, preliminary research with 

Asian Americans in community-based substance 

abuse treatment found no overall group 

differences in treatment retention and outcomes 

(Niv et al. 2007). 

Resiliency factors 

As mentioned above, Asian and Pacifi c 

Americans share an ethic of hard work and 

family orientation, as well as a cultural concept 

of interrelatedness among family, community, 

environment, and spiritual world. In addition, 

the following observations have been noted in 

the literature: 

• 	If incorporated thoughtfully into the 

treatment process, the family can have a 

signifi cant influence on treatment outcome. 

At the very least, consideration should be 

given to the family’s role in substance abuse 

as well as to members’ participation in 

treatment and influence on recovery (Chang 

2000). 

• 	 Some clients might find incorporation of 

indigenous treatment modalities—such 

as healing ceremonies, acupuncture, 

meditation, massage, tai-chi, and herbal 

medicines—helpful (Kitano and Louie 2002). 

118 Substance Abuse Among Specific Population Groups and Settings 
American-Indian and AlaskaNative Women 

Demographics 

In the 2000 census, those who reported Alaska 

Native or American Indian as their only race/ 

ethnic group totaled nearly 2.5 million, while the 

number reporting Alaska Native or American 

Indian in combination with another race/ethnic 

group numbered 4.1 million (U.S. Census Bureau 

2001e), or 1.5 percent of the U.S. population. 

Alaska Native/American Indian is the smallest 

of the four major racial/ethnic groups currently 

recognized in the United States. Their small 

numbers, however, mask signifi cant diversity. 

The largest concentrations of Native people 

reside in three States: Arizona, California, 

and Oklahoma (U.S. Census Bureau 2001f). 

However, American Indians and Alaska Natives 

may live anywhere in North America on and 

off reservations or other forms of tribal land, 

in rural or urban areas, and within villages 

(Coyhis 2000). Today, American-Indian and 

Alaska-Native nations (e.g., Navajo, Iroquois) 

encompass more than 560 federally recognized 

Tribes, including more than 220 Alaskan 

villages, in addition to numerous Tribes that are 

not yet federally recognized. Historically, this 

diversity, as well as the separation of this group 

into many small segments scattered throughout 

the United States, has complicated efforts to 

identify commonalities through classifi cation 

(NIH; ORWH 1999). Nevertheless, some 

experiences shared by many Tribes have been 

noted (NIH; ORWH 1999): 

• 	 Rapid change from a cooperative, selfsufficient, clan-based society to a familybased community dependent on trade 

• 	 Prior government criminalization of the use 

of native language and spiritual practices 

• 	 Deaths of members of the older generations 

to infectious diseases and war 

• 	 Loss of the ancestral lands 

The rates of unemployment, poverty, and 

education; poor health status; and alcohol 

and drug use vary by Tribe and by region. 

The current poverty level is 27 percent among 

Native Americans (U.S. Census Bureau 2006). 

Unemployment hovers at about 13 percent 

for females older than age 16 (Indian Health 

Service [IHS] 2002). The proportion of family 

households maintained by women with no 

spouse is approximately 21 percent (U.S. Census 

Bureau 2000). 

Substance use among American 

Indians and Alaska Natives 

Although representing only 1.5 percent of 

the U.S. population, American Indians/ 

Alaska Natives represented 2.1 percent of all 

admissions to publicly funded substance abuse 

treatment facilities. Of these, 36 percent were 

female (SAMHSA 2004). Based on the NSDUH, 

including alcohol and illicit drugs, Native 

American women were more likely than any 

other ethnic group to have met criteria for past 

year need for substance abuse treatment (OAS 

2006a). For more comprehensive information 

on substance abuse treatment, see the planned 

TIP Substance Abuse Treatment with American 

Indians and Alaska Natives (CSAT in 

development e). 

Alcohol 

Nearly 14 percent of Native-American women 

were dependent on or abused alcohol between 

2004 and 2005 (SAMHSA 2007). Compared 

with other substances, alcohol was by far the 

most frequently reported reason (52 percent) 

for admission to a treatment facility among 

women (OAS 2006a). The data also show that 

this group initiates alcohol use at an earlier 

age than other racial/ethnic groups (SAMHSA 

2004). Among women of all races aged 35 to 44, 

4.9 per 100,000 died of alcohol-related disease. 

However, the alcohol-related death rate among 

American-Indian and Alaska-Native women in 

this age range is 67.2 per 100,000 (IHS 2002). 

According to the CDC (2001), American-Indian 

women have higher rates of alcohol abuse, 

chronic liver disease, and cirrhosis than any 

other racial/ethnic group in the United States. 

Illicit drug use 

Among Native Americans, the rate of current 

illicit drug use (12.6 percent) is higher than 

Substance Abuse Among Specific Population Groups and Settings 119 
any other race or ethnicity in United States 

according to the NSDUH (SAMHSA 2006). 

After alcohol abuse, the most common cause for 

Alaska Native and American Indian admission 

to treatment is methamphetamine (15 percent; 

SAMHSA 2006), followed by marijuana 

(13 percent), and cocaine/crack (7 percent; 

SAMHSA 2006). According to one study 

investigating gender differences among Alaska 

Natives in inpatient treatment (Malcolm et al. 

2006), women reported higher rates of cocaine 

dependence in addition to alcohol dependence 

while men had higher rates of marijuana and 

alcohol dependence. Although the trend for 

inhalant abuse is declining among American 

Indians, studies have shown that AmericanIndian females are using inhalants more than 

American-Indian males (Beauvais et al. 2002). 

Among urban American-Indian women who 

abuse drugs, Stevens (2001) found that most 

lived below the poverty level, were unemployed 

and homeless, experienced a particularly high 

number of pregnancies and stillbirths, and had 

children remanded to the custody of State and 

tribal child protective services. 

Clinical treatment issues 

Substance use patterns and treatment issues 

among many groups of American Indians 

and Alaska Natives have not been studied 

adequately; as a result, many issues specifi c to 

these groups are not well known. Overall, wide 

variations in alcohol and drug use patterns— 

along with access to treatment and other needed 

health services—exist across American-Indian 

and Alaska-Native communities (Berkowitz et 

al. 1998; Vernon 2007). While similar barriers 

exist for Native-American women in comparison 

to other women with substance use disorders, 

Native-American women often encounter more 

barriers that impede access to treatment; i.e., 

economic hardships, treatment accessibility, 

lack of screening and assessment, and genderresponsive programming (Berkowitz et al. 1998; 

Parks et al. 2003). 

Comprehensive attention to health care 

and health status is crucial for treatment of 

American-Indian and Alaska-Native women. 

Stevens (2001) suggests that medical and 

substance abuse treatment providers need 

to work hand-in-hand to meet the needs of 

Native-American women, and that primary care 

providers should routinely screen for alcohol 

and drug abuse and discuss the negative health 

consequences of substance use in a culturally 

responsive manner during regular examinations. 

Unfortunately, few American-Indian and 

Alaska-Native women who abuse alcohol and 

illicit drugs are referred or enrolled in treatment 

programs of any type. For Native-American 

women living in rural areas, available treatment 

programs usually are neither woman-centered 

nor culturally specific. Moreover, many NativeAmerican women are reluctant to attend 

treatment programs with non-Native Americans 

(Hussong et al. 1994). Some prefer participating 

in reservation-based programs, while others may 

be reluctant to participate in small community 

programs or urban health centers due to 

concerns surrounding confi dentiality (Jumper 

Thurman and Plested 1998). Others may seek 

treatment elsewhere but express concerns 

surrounding available support upon reentering 

the reservation after treatment (Berkowitz et al. 

1998). Subsequently, Native-American women 

are more likely to need help deciding on the 

location of their treatment program. 

Trauma-informed services 

American-Indian women are disproportionately 

affected by violent crimes, childhood sexual 

abuse, and physical abuse. Nearly three-fourths 

(73.3 percent) of Alaska-Native women in 

one program reported sexual abuse histories 

(Brems 1996). Beyond specific traumas among 

Native Americans, treatment programs need to 

incorporate a culturally responsive framework 

that understands and addresses the legacy 

of historical and cumulative trauma (Robin 

et al. 1997), including forced acculturation 

and deculturalization (e.g., loss of cultural, 

community, individual identity) of AmericanIndian and Alaska-Native communities. These 

losses have sometimes been expressed in higher 

suicide and homicide rates among NativeAmerican community members. As part of 

recovery, women will likely need to address the 

loss of family members or friends. Likewise, 

120 Substance Abuse Among Specific Population Groups and Settings 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and Native-American Women 

Clinical: 

• 	 Assess for the history of traumatic events, including sexual and physical abuse, and 

the diagnosis of PTSD. 

• 	 Provide trauma-informed services that encompass the impact of cumulative stress 

from historical trauma to specifi c trauma. 

• 	 Recognize that the role of “helper” may extend beyond substance abuse counseling 

to seeking advice for other health concerns, for other family members, or for other 

life circumstances or stressors. 

• 	 Acknowledge the importance of family history and extended family members, and as 

deemed appropriate, involve family members during the course of treatment. 

• 	 Explore the woman’s beliefs regarding healing and knowledge of cultural practices. 

Don’t assume that a Native-American woman follows traditional practices. 

• 	 Understand and acknowledge the specific Tribe’s cultural values, beliefs, and practices, 

including customs, habits, sex roles, rituals, and communication styles. 

Program Development: 

• 	 Take time to invest in the individual Native community and learn the perceptions 

toward non-Native counselors. 

• 	 Use treatment as a prevention opportunity for FASD. Provide an interactive program 

that not only educates women on the cause and prevalence of FAS and Fetal Alcohol 

Effects (FAE), but provides an understanding of the behavioral effects that are often 

associated with this syndrome. 

• 	 Incorporate comprehensive HIV/AIDS prevention and intervention services into 

treatment. 

• 	 Adopt trauma-informed services and consider an integrated model of specifi c services 

for substance-use disorders and trauma. 

• 	 Combine contemporary approaches with traditional/spiritual practices; i.e., medicine 

wheel, “Red Road to Wellbriety” (White Bison), smudging, sweat lodge ceremony, 

and talking circle. 

• 	 Implement a skills training program to help Native-American clients learn how to 

successfully negotiate both traditional and majority cultures after treatment (Hawkins 

and Walker 2005). 

Staff Training: 

• 	 Promote an understanding of the role of historical and intergenerational trauma as 

well as cultural oppression along with its impact on Native-American clients and its 

role in substance abuse. 

• 	 Provide learning opportunities that highlight the nature, history, and diversity of 

American-Indian and Alaska-Native communities. 

• 	 Address biases and myths associated with Native-American clients; e.g., fi rewater 

myth. 

• 	 Invest in learning the various and specific cultural patterns in coping with stress that 

may be unique to the specific community or Tribe. 

Substance Abuse Among Specific Population Groups and Settings 121 
Advice to Clinicians and Administrators:Substance Abuse 

Treatment and Native-American Women (continued) 

Staff Training (continued): 

• Review and discuss the prevalence of HIV/AIDS, FASD, suicide and violence, and other 

health related risks among Native-American communities. 

• Use local tribal members as resource people in training and as staff members in 

treatment programs. 

Source: Coyhis 2000; Evans-Campbell 2008; and Trimble and Jumper Thurman 2002. 

screening for traumatic events, posttraumatic 

stress disorder (PTSD), grief, and depressive 

symptoms should be routine. Treatment 

programs for Native-American women need 

to incorporate culturally congruent traumainformed and integrated trauma services to 

build a stronger bridge to recovery (Saylors and 

Daliparthy 2006). 

HIV/AIDS prevention and 

intervention comprehensive 

services 

In 2005, Native Americans ranked third in 

HIV/AIDS rates, with Native-American women 

accounting for 29 percent of the diagnoses. 

While rates vary from community to community 

(Vernon and Jumper Thurman 2005), the rise 

in HIV/AIDS cases among Native-American 

communities refl ects the 

need for attention in 

program development 

and treatment services

for substance use

disorders among women. 

Simoni and colleagues 

(2004) coined the term

“Triangle of Risk” in 

reference to the HIV 

risk factors: history of 

sexual trauma, injection

drug use, and HIV

sexual risk behaviors. 


Each risk factor is 

highly interrelated to 

the other factors and 

strongly associated 

“The work we 

do today will 

provide for the 

freedom of our 

future generations 

(Mohawk).” 

Source: The Freedom 

Way: The Native American 


Program at the Margaret 

A. Stutzman Addiction 	

Treatment Center, NY	 

with substance use disorders. While risk 

factors are not limited only to the “triangle of 

risk” (Vernon 2007), the prevalence of these 

risk factors clearly represents the necessity 

of comprehensive HIV/AIDS prevention and 

intervention services among Native-American 

women seeking treatment for substance abuse. 

Fetal alcohol prevention services 

Fetal Alcohol Spectrum disorders (FASD) 

are very serious problems in some Native 

communities. A four-State study showed that 

fetal alcohol syndrome (FAS) among American 

Indians and Alaska Natives occurred at the 

rate of 3.2 per 1,000 population over a 2-year 

period, compared with 0.4 per 1,000 in the total 

population of the same four States (Hymbaugh 

et al. 2002). As a means of prevention, 

gender-responsive treatment services have an 

opportunity to educate Native-American women 

on the impact of alcohol and drugs on fetal 

development. By adding prevention approaches 

for FASD in treatment, women can make better 

and more informed decisions regarding alcohol 

use during pregnancy. 

Culturally congruent substance 

abuse services 

Treatment professionals must approach health 

and well-being through the complementary 

lenses of culture, history, and the beliefs of 

Native-American people (LaFromboise et 

al. 1998; Stevens 2001). For many NativeAmerican women, the journey to reclaim their 

identities and culture is central to recovery 

(Brems 1996). The most critical feature for 

122 Substance Abuse Among Specific Population Groups and Settings 
treatment of American-Indian and AlaskaNative women is that programs be culturally 

responsive, gender-responsive, and communitybased, and that they “reaffirm cultural values 

and consider the individual in the context of 

the community” (LaFromboise et al. 1998, p. 

150). A series of IHS-funded focus groups for 

women in treatment found that an emphasis on 

cultural activities was important to the women 

(Berkowitz et al. 1998), including sweat lodges, 

powwows, talking circles, tribal music and 

crafts, traditional foods, and meetings with 

medicine people and tribal elders. For many 

women, participating in tribal activities gave 

them a sense of belonging—some for the fi rst 

time (Berkowitz et al. 1998). This is important 

because the reasons that some Native-American 

women have given for alcohol and drug use 

include low self-esteem and “not fitting in with 

the white world” (Hussong et al. 1994). While 

it should not be assumed that every NativeAmerican woman is traditional; traditional 

healing should be made available as a treatment 

option or as an adjunct to treatment. 

Family and community 

involvement 

Strong ties to family and community make 

community-based approaches appropriate 

because substance abuse is considered a family 

and community problem (Berkowitz et al. 1998). 

In some Native-American communities, alcohol 

consumption is the norm; abstainers may be 

ostracized. When drinking together is a major 

family activity, the woman who abstains may, 

in effect, lose her family. With such high rates 

of alcohol and drug use, a woman’s family and 

friends are unlikely to offer strong support for 

recovery. By acknowledging the role and the 

importance of family and community in either 

perpetuating the substance use or in providing 

a nurturing recovery environment, treatment 

providers must involve family and community 

members from the outset. As highlighted in 

the IHS-funded research on substance abuse 

treatment for Native Americans, comprehensive 

treatment must embrace and encourage 

community involvement and commitment to 

support long-term recovery (Berkowitz et al. 

1998). Literature suggests that the key factor in 

maintaining abstinence among Native-American 

women is the presence of tangible support 

(Oetzel et al. 2007). 

Resiliency factors 

In recent years, American-Indian communities 

have organized to promote their economies 

and cultures. In the mid-1990s, an Executive 

Order mandated the establishment of tribal 

colleges on or near reservations, and at least 50 

percent of the registered student population of 

these colleges must, by definition, be American 

Indians or Alaska Natives. Currently, American 

Indians are developing economic enterprises in 

the casino, recreation, and computer industries. 

Along with these advances, American-Indian 

and Alaska-Native peoples are revitalizing their 

native languages and cultures. Recent trends 

include movement back to the reservation. In 

addition, many American-Indian communities 

are very proactive about substance abuse issues. 

On reservations, many women have gone back to 

talking circles and are promoting the need to do 

things within cultural, family, and community 

contexts, including the creation of communities 

that are alcohol free (Berkowitz et al. 1998). The 

Williams Lake Band in Canada, for example, 

has become entirely alcohol and drug free. 

Another success story involves the Alkali Lake 

Band in British Columbia, which achieved a 

communitywide sobriety rate of 95 percent over 

a 15-year period (Berkowitz et al. 1998). 

Sexual Orientation and 

Women 

Demographics 

Several factors prevent an accurate measure 

of the number of women who identify as 

lesbian or bisexual, among them the absence 

of standardized terms and definitions of sexual 

orientation and gender identity (Dean et al. 

2000). However, general estimates of sexual 

orientation as lesbian or bisexual range from 1 

to 10 percent of the female population (Laumann 

et al. 1994; Michaels 1996). 

Substance Abuse Among Specific Population Groups and Settings 123 
Hughes and Eliason (2002) present defi nitions 

that are inclusive and highlight the differences 

between sexual orientation and gender identity. 

Their definition of “lesbian” or “gay” is “a 

woman or man whose primary sexual and 

emotional attachments are to persons of the 

same sex” (p. 266). “Bisexual” refers to “men 

or women who have sexual and/or emotional 

attachments to both men and women” (p. 266), 

although typically not at the same time. 

Substance Use Among Lesbian 

and Bisexual Women 

Limited research on alcohol and drug abuse has 

focused on issues related to sexual orientation 

(Hughes and Eliason 2002). What is known, 

however, is that within-group differences are 

significant. Early research attempts, specifi cally 

methods of data collection, may have reinforced 

misconceptions and stereotypical interpretations 

of substance use within these groups. Studies 

in the 1970s and 1980s revealed high rates of 

alcohol use and abuse among lesbians,, yet 

most surveys were conducted at bars. Other 

methodological limitations that remain consistent 

to the present time are sample size and absence 

of control groups (Hughes and Eliason 2002). 

In addition, studies that evaluate drug patterns 

are often focused on gay men. Little is known 

about illicit and prescription drug abuse 

patterns among lesbian and bisexual women. 

In two population-based studies, researchers 

found more drug use and heavy drinking 

among bisexual and lesbian women than among 

heterosexual women (Diamant et al. 2000). 

Alcohol 

Later research (Cochran et al. 2000; Hughes et 

al. 2000) supports the idea that earlier estimates 

of the relationship between sexual orientation 

and alcoholism are inflated. Nonetheless, these 

and other studies (Case et al. 2004; Cochran et 

al. 2000, 2001; Cochran and Mays 2000; Gilman 

et al. 2001; Parks and Hughes 2005; Sandfort 

et al. 2001) suggest that lesbian women—in 

comparison to heterosexual women—are more 

likely to use and abuse alcohol, less likely to 

decrease their use of alcohol with age, and 

more likely to report alcohol-related problems. 

Literature suggests that this greater prevalence 

of substance use and abuse may be related to 

more opportunities to drink, fewer traditional 

sex role expectations, and different social 

conventions about drinking (Hughes and 

Wilsnack 1997). 

Illicit drugs 

While little is known about drug patterns 

among lesbian and bisexual women, research 

suggests that they are at a heightened risk for 

drug use, with specific subpopulations showing 

more prevalence, such as young adult lesbian 

women (Hughes and Eliason 2002). In two 

studies (Cochran et al. 2004; Corliss et al. 2006), 

researchers report that women with female 

sexual partners had at least one symptom of 

dysfunctional drug use and were more likely to 

display impairment and meet criteria for any 

drug dependence in comparison to heterosexual 

women. Lesbians report greater problems 

associated with marijuana, cocaine, and 

hallucinogens. In a study conducted in urban 

primary care sites, bisexual women were about 

twice as likely as heterosexual women to report 

having used illicit drugs in the past month (Koh 

2000). 

Clinical Treatment Issues 

Few studies of substance use disorders have 

included sufficient numbers of lesbian women 

to permit separate analyses, and no studies 

have focused exclusively on bisexual women. 

In the few studies that are available, fi ndings 

are inconclusive regarding the effi cacy of 

separate treatment groups. Only 6 percent of 

substance abuse treatment services offer special 

programs or group therapy for gay men and 

women (SAMHSA 2005). For a comprehensive 

overview of treatment issues among lesbian and 

bisexual women, review SAMHSA’s Center for 

Substance Abuse Treatment (CSAT) manual, 

A Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and 

Transgender Individuals (CSAT 2001b). This 

manual provides information to administrators 

and clinicians about appropriate diagnosis and 

treatment approaches that will help ensure 

124 Substance Abuse Among Specific Population Groups and Settings 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and Lesbian and Bisexual Women 

Clinical: 

• Explore coping style and enhance coping skills needed to manage stress associated

with self-disclosure and the habitual “coming out” process, to deal with attitudes 

from others regarding sexual orientation, and to address feelings of alienation from 

family members who are rejecting of sexual orientation. 

• In addition to appropriate family members, consider friends as a vital component

of treatment and support structure. Studies (Kurdek and Schmitt 1986; Mays et al. 

1994) report that lesbians generally receive greater support from friends than from 

family. By using social support from family and friends, counselors will likely enhance 

psychological well-being. 

• Assess for interpersonal violence. Rates pertaining to partner violence or abuse among

lesbian women are similar to those of heterosexual women (see, e.g., Coleman 1994; 

Renzetti 1994) and partner abuse often is accompanied by alcohol use (Schilit et al. 

1990). Assess for the history of traumatic events, including sexual and physical abuse, 

and the diagnosis of PTSD. 

Program Development: 

• Consider a specialized group that addresses issues unique to lesbians in recovery. 

• Implement policies that address the potential woman-to-woman sexual relationships

that can develop in residential treatment (similar to man-to-woman relationship 

policies in treatment). 

• Incorporate educational components in treatment that address relevant legal issues

and the inherent issues that may arise in addressing medical, child custody, and 

fi nancial needs. 

Staff Training: 

• Provide education on the multiple risk and protective factors that may either increase

or buffer risk for substance use disorders. 

• Impart knowledge about legal issues, including living wills, powers of attorney, 

advance directives, restrictions imposed by HIPAA, as well as a referral base to assist 

lesbians in securing these services. 

• Address myths and stereotypes associated with gender roles and sexual behaviors,

including the possible assumption that lesbians in relationships play either male 

or female roles or they are hypersexual or promiscuous. It is important for staff to 

recognize that lesbian relationships maintain the same patterns of stability and sexual 

behavior as heterosexual relationships. 

• Review supportive strategies in assisting clients in determining whether or not to selfdisclose sexual orientation in treatment. 

• Assist staff to understand the impact of stigma associated with lesbian and bisexual 

women. 

• Review the “coming out” process and the stages of identity. 

Source: Ayala and Coleman 2000; CSAT 2001b; Jordan and Deluty 1998; Oetjen and 

Rothblum 2000; Wayment and Peplau 1995. 

Substance Abuse Among Specific Population Groups and Settings 125 
 

the development or enhancement of effective 

lesbian, gay, bisexual, and transgender (LGBT)­

sensitive programs. 

Sexual Orientation and 

Women of Color 

Prevalence studies of substance use and abuse 

in lesbian, gay, and bisexual populations rarely 

have included sufficient numbers of racial and 

ethnic minority persons to permit separate 

analyses. However, limited available data 

suggest that patterns of substance use among 

lesbian women of color are more similar to those 

of their Caucasian lesbian counterparts than 

to those of their heterosexual racial and ethnic 

counterparts (Hughes and Eliason 2002). All 

racially and ethnically diverse group members 

face similar responses to their sexual orientation 

that can be stressful to psychological wellbeing, and reluctance to seek professional help 

can increase further their risk for negative 

psychological outcomes (Greene 1997). 

Social support for treatment is known to be 

important in helping women stay in treatment 

and avoid relapse. Although African-American 

lesbian and bisexual women may receive support 

from fewer sources than African-American 

heterosexual women when they are in treatment 

for alcohol dependence, the quality of that 

support appears the same for the two groups 

(Mays et al. 1994). African-American gay women 

may prefer counselors of the same race who 

identified themselves as lesbians (Matthews and 

Hughes 2001). 

Relatively little is known about alcohol abuse 

among Hispanic/Latina lesbian and bisexual 

women, although some researchers (Nicoloff and 

Stiglitz 1987; Peluso and Peluso 1988) believe 

it is more prevalent among Hispanic/Latina 

lesbian women than heterosexual Hispanic/ 

Latina women (Reyes 1998). 

For Asian Americans, cultural issues play a 

major role in sexual identity and culturally 

normative behavior. Asian-American lesbian 

women pose a cultural dilemma by virtue of 

their individual and sexual identifi cation. If 

sexuality is expressed without jeopardizing 

family integrity and the individual’s role in the 

family, then it may be tolerated (Chan 1997). 

Many Asians find it difficult to conceive of 

losing that familial connection and are therefore 

uncomfortable with assuming a minority sexual 

identity. Given this context, it is likely that Asian 

Americans who are openly lesbian probably are 

relatively acculturated. Chan (1989) found that, 

although they identify both with their AsianAmerican and lesbian identities, most of these 

women identify more strongly as lesbian. The 

implications of this with regard to substance 

abuse remain unexplored. 

American Indians and Alaska Natives 

traditionally uphold a worldview that all things 

are interrelated and dependent upon one 

another. Identity formation, specifi cally sexual 

identity, is conceptualized through this broader 

lens. Therefore, sexual identity is typically 

not defined using definitive terms, such as 

lesbian or bisexual, but rather through more 

expansive concepts that embrace roles within 

the culture and community. Native Americans 

are more likely to use the term “two-spirit” to 

capture both male and female sexuality and 

gender expression (Evans-Campbell et al. 2005). 

Research focused on substance use disorders 

among two-spirited Native Americans is limited, 

and empirical literature highlighting two-spirit 

women is non-existent. In a study comparing 

two-spirited men and women with Native 

heterosexual peers, two-spirit individuals had 

significantly higher rates of lifetime illicit drug 

use; greater sustained drinking among urban 

Natives; and greater likelihood to use alcohol to 

increase sociability, regulate mood, and decrease 

anxiety and feelings of inferiority (Balsam et al. 

2004). 

Resiliency Factors 

In general, lesbian women are more likely to 

have long-term relationships and friendships 

similar to heterosexual women. The stability 

in relationships may provide a strong platform 

in recovery provided the environment does not 

support or encourage continued alcohol abuse 

or drug use. Moreover, the woman’s fortitude 

126 Substance Abuse Among Specific Population Groups and Settings 
in managing prejudice and discrimination as a 

direct result of sexual orientation may provide 

a powerful example and symbol of personal 

strength in working toward recovery. 

Women in Later Life 

Demographics 

Approximately 21 million women aged 65 

and older reside in the United States. In 

2003, women accounted for 58 percent of 

the population aged 65 and older (Federal 

Interagency Forum on Aging-Related Statistics 

[FIFARS] 2004); women older than age 65 

constitute 7.3 percent of the total population. 

The oldest of the population (persons 85 years 

and older) are among the most rapidly growing 

age cohort in the Nation. The increasing number 

of older women corresponds to a growing 

incidence of health-related problems that were 

once considered solely men’s diseases. 

A Hidden Disease 

Older years are filled with many adjustments 

and challenges, often including loss of spouse 

and close friends, retirement, and reduced 

income. Some women turn to alcohol or drugs to 

help meet these life changes. Because many older 

women live alone (40 percent of those aged 65 

and older [FIFARS 2004]), their substance use 

is difficult to measure (Moore et al. 1989). Older 

women tend to hide their substance use because 

they attach greater stigma to it than men do 

(CSAT 1998d). Older women are less likely than 

older men to drink or use drugs in public, so 

they are less likely to drive while intoxicated 

or engage in other behavior that might reveal a 

substance use disorder (SAMHSA 2008). 

Substance use disorders in older women often 

go undetected by primary care professionals 

because of a lack of appropriate diagnostic 

criteria and because many signs of abuse can be 

mistaken for other conditions more prevalent 

in later life (e.g., cognitive impairment, anemia, 

physiological consequences from falls). It is 

not unusual for older patients to show poor 

compliance with the recommended use of 

their medications (Menninger 2002). TIP 26 

Substance Abuse Among Older Adults (CSAT 

1998d), recommends best practices to identify, 

screen, assess, and treat alcohol, prescription 

medication, and other drug abuse among people 

aged 60 and older. 

Risk Factors 

Alcohol dependence and prescription drug abuse 

are the top two substance use issues for older 

women (CSAT 1998d). Numerous risk factors 

are associated with substance-related problems 

among older women including losses or deaths, 

financial problems, health problems, age-related 

changes in metabolism, synergistic effects 

in combining alcohol and other drugs, and 

changing roles (Epstein et al. 2007). Researchers 

found that when women were deprived of their 

usual roles as wife, mother, or employee, their 

problem drinking increased. Older women 

with fewer role demands have fewer competing 

activities (Wilsnack and Cheloha 1987). 

Timing of Onset 

Alcohol- and drug-related problems in older 

women can be longstanding or can begin in later 

life. Women with early-onset alcohol dependence 

have a high incidence of major depression, 

anxiety, and bipolar disorder and simply 

continue their drinking habits as they age (CSAT 

1998d). Women with late-onset use appear both 

physically and psychologically healthier. They 

are more likely than those with early-onset use 

to have begun or increased drinking in response 

to a recent loss such as death or divorce. Both 

groups appear to use alcohol almost daily 

outside the home and at home alone and are 

likely to use alcohol to respond to hurts and 

losses (CSAT 1998d). 

Substance use among women in 

later life 

Alcohol 

In comparing trends from 1992 to 2002 in 

alcohol abuse and dependence among women 

as they age, the National Epidemiologic Survey 

on Alcohol and Related Conditions showed a 

significant inverse relationship between rates of 

dependence and successive age groups—that as 

Substance Abuse Among Specific Population Groups and Settings 127 
Signs of Alcohol-Dependence and/or Drug Abuse in an Older Woman 

• Neglected appearance and poor hygiene 

• Frequent car accidents 

• Numerous physicians and prescriptions 

• Neglect of home, bills, pets, etc. 

• Malnutrition and anemia, and empty food cupboards 

• Withdrawal from social activities and self-isolation from family and friends 

• Mood swings or erratic behavior 

• Repeated falls or evidence of falls (leg bruises) 

• Urinary incontinence 

• Cigarette burns 

• Attempts or thoughts of suicide 

• Depression 

• Unexplained chronic pain or other health complaints 

• Confusion and/or memory impairment 

• Blurred vision or blackouts 

• Seizures or tremors 

Source: Cohen 2000; CSAT 1998d 

women age, prevalence of alcohol dependence 

decreases (Grant et al. 2006). While there is 

earlier empirical evidence to support that latemiddle-age to older women have fewer drinking 

problems (known as “maturing-out”; Brennan 

et al. 1993), this trend has to be approached 

with a conservative lens since older women 

tend to hide their use and not seek alcohol 

treatment. In addition, the prevalence and 

risk of alcohol abuse and dependence among 

women appears to vary among subgroups. For 

example, widowed women were found to be 

three times more likely than married women 

to drink heavily (The National Center on 

Addiction and Substance Abuse at Columbia 

University [CASA] 1996). The most consistent 

predictors of alcohol-related problems among 

women were friends’ approval of alcohol use, 

financial stressors, and avoidance coping (Moos 

et al. 2004). 

Prescription Drugs 

Prescribed medications are the most common 

drugs of abuse, outside of alcohol, among 

older adults (National Institute on Drug Abuse 

[NIDA] 2001). Approximately 30 percent 

of all prescriptions and 40 percent of all 

benzodiazepine prescriptions are prescribed 

to elderly individuals. An older woman is more 

likely than an older man to visit a physician 

and to be prescribed a psychoactive drug. 

Problems can result if prescriptions are written 

by several physicians who do not know the 

full range of prescribed and over-the-counter 

medications being taken. Older women often 

are prescribed medications highly susceptible 

to abuse (NIDA 2001). Medications frequently 

prescribed for and used by older women include 

anxiolytics and sedative-hypnotics. Alcohol– 

drug interactions are more likely to occur 

among older adults simply because they take 

more medications than younger adults and may 

continue to drink at levels consistent with earlier 

patterns. These interactions can cause problems 

in older adults because of slowed metabolism in 

later life and greater reliance on medications for 

chronic medical conditions (CSAT 1998d). With 

128 Substance Abuse Among Specific Population Groups and Settings 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and Older Women 

Review TIP 26 Substance Abuse Among Older Adults (CSAT 1998d), for further guidance 

in providing substance abuse treatment to older women. 

Clinical: 

• Introduce coping strategies, including relaxation methods, to enhance feelings of

self-efficacy in handling life stressors. 

• Incorporate counseling services that address issues of grief along with substance

abuse treatment as needed. 

• Use additional resources to reinforce the need for and support of treatment

including, but not limited to, extended family members, healthcare providers, faithbased services, etc. 

• Incorporate behavioral activation therapy to help address depressive symptoms

among older women who have substance use disorders. This behavioral approach 

helps clients to recognize the connection between life stressors, mood, and less 

effective coping behaviors. It encourages and provides strategies to help the client 

to monitor mood and daily activities with an emphasis on strategies to increase the 

number of enjoyable activities (Cuijpers et al. 2007). 

• Recognize and address the potential losses associated with changes in caregiver roles.

Program Development: 

• Create access to treatment through nontraditional delivery; e.g., home-based or

mobile community services. 

• Provide educational programs on metabolism and interaction of alcohol and drugs,

particularly prescription medications, at senior citizen centers. 

• Create addiction treatment services or programs designed for older adults only. 

• Provide home services or develop a one-stop multidisciplinary program that provides

needed healthcare and nutritional services, psychoeducational groups, fi nancial 

services, transportation, counseling, etc. 

Staff Training: 

• Review the more common signs of drug misuse among older women, including

mental and physical symptoms as well as suspicious requests for refi lls. 

• Provide an introduction to prescription drugs with emphasis on the physiological

effects of anxiolytics and sedative hypnotics. 

• Provide education on the physiological impact of alcohol and drug intake among

older women. 

• Emphasize the heightened alcohol sensitivity among women and the increased

vulnerability among older women. 

• Explore the relationship between alcohol problems and higher rates of depression

and prescription drug use. 

• Address the need and roles of a multidisciplinary treatment to ensure quality of care

for older women in substance abuse treatment. 

Source: Eliason and Skinstad 2001; Satre et al. 2004; Scogin et al. 2007. 

Substance Abuse Among Specific Population Groups and Settings 129 
age-related changes, prescription medications 

are more potent, less predictable in effects, and 

more likely to increase negative outcomes (Allen 

et al. 2006). 

Clinical Treatment Issues 

Screening and brief interventions, particularly 

cognitive–behavioral and case management 

approaches, may be especially useful in limiting 

alcohol abuse in older women; although research 

with older women has been limited, results 

are promising (Blow and Barry 2002). Alcohol 

dependence in an older woman may be observed 

first when she presents at an acute-care medical 

setting with complaints such as depression, 

memory loss, frequent falls, or chronic pain that 

may have been exacerbated by alcohol. These 

are not and should not be presumed to be normal 

consequences of aging. This is an appropriate 

time to intervene and discuss the benefi ts of 

sobriety as well as treatment options. 

Treatment should be supportive, respectful, 

and non-confrontational. If possible, providers 

should gather personal information about the 

client from family members, neighbors, clergy, or 

others with the client’s permission. Labels such 

as “alcoholic” or “addict” should be avoided 

and replaced with words such as “drinking” 

and “drinking problem” (Cohen 2000). It is 

important to be direct and honest, to explain 

that assistance is available, and to provide 

instructions on where help can be secured. A 

substance abuse treatment professional can 

help the older woman develop a support system. 

Some women may respond better if approached 

about their drinking in the safety of their homes 

or at a familiar medical facility where they 

feel comfortable. Programs such as Alcoholics 

Anonymous can be an important resource, 

particularly if the group meets during the day 

and is composed of older women. 

A well-coordinated approach to substance abuse 

treatment for older women should include an 

interdisciplinary treatment team with family 

or significant others involved in a plan of 

individualized support services. Since it may 

be difficult to address the needs of older women 

in residential treatment programs (where the 

majority of clients are much younger), treatment 

may be more effective when delivered at senior 

centers, congregate meal sites, outpatient 

geriatric medical programs, nursing homes, 

home care programs, or peer outreach (Cohen 

2000). Recent studies are providing promising 

results. In an outcome study comparing men’s 

and women’s abstinence rates in an outpatient 

group, 79 percent of women reported abstinence 

from alcohol at the 6-month followup, compared 

to 54 percent of the men (Satre et al. 2004). 

Resiliency Factors 

Using a strengths-based narrative approach can 

help capitalize on each woman’s life experiences 

and give meaning to her recovery. By providing 

an opportunity to explore her life events, 

history, personal attributes, and triumphs in 

spite of adversity, counselors can use this history 

to help reinforce the woman’s resilience and 

abilities to support recovery. 

Women in Rural America 

Demographics 

Rural America contains 17 percent of the U.S. 

population (Economic Research Services 2007). 

In many rural areas, the population is aging 

steadily. Rural areas have a higher proportion 

of older persons and higher poverty rates 

among the elderly than urban areas, and women 

constitute 65 percent of the rural poor age 65 

and older. In addition, poverty rates in rural 

settings are three times higher for widows than 

for married women (USDA 2007). 

In reviewing specific hardships that may not 

be independent of the effects of either chronic 

or acute alcohol and drug use, a welfare 

study identified common material hardships 

experienced by women. More than 56 percent 

of rural women respondents report unmet 

medical needs and telephone disconnection 

as the most prevalent hardships, followed by 

food insufficiency, housing problems, improper 

winter clothing, and utility disconnection (USDA 

2007). With added burdens generated by age, 

substance abuse, and poverty, local communities 

130 Substance Abuse Among Specific Population Groups and Settings 
are faced with many challenges in meeting the 

diverse needs of women in rural settings. 

Substance Use Among Women in 

Rural Settings 

Substance abuse is a major rural health 

concern. While alcohol and drug patterns vary 

little across most age groups in urban and rural 

settings, emerging patterns among rural youth 

show a rise in use—thus providing a forecast 

of potential patterns of abuse and dependence. 

While rural and urban areas experience similar 

drug-use problems, the consequences may 

be greater in rural areas because of limited 

access to health care and substance abuse 

treatment. For example, only 10.7 percent of 

hospitals in rural areas offer substance abuse 

treatment services compared to 26.5 percent of 

metropolitan hospitals (Dempsey et al. 1999). 

Currently, there are minimal studies focused 

on substance use disorders among rural women 

(Boyd 2003). 

Risk factors for substance use disorders among 

women living in rural areas of the United 

States are significant. Many rural families are 

impoverished, and women often experience 

stress associated with limited resources (Boyd 

1998). A history of childhood victimization is 

another risk factor for substance use disorders 

among rural women, as for all women. A 

qualitative study described rural women’s 

perspectives on becoming alcohol dependent, 

and many reported some form of sexual abuse. 

This study reported that some rural women 

began drinking in adolescence as a means of selfmedication to ease the pain of their problems 

(Boyd and Mackey 2000a, b). 

Alcohol 

Beliefs and expectations about alcohol strongly 

predict potential alcohol abuse. Women in some 

rural communities hold more positive beliefs 

about alcohol than those in other communities 

or in comparison to urban women. The beliefs 

involve the notion that alcohol enhances sexual, 

physical, and social pleasure; reduces tension; 

and increases arousal, power, and control over 

life circumstances (Boyd 1998; Marlatt et al. 

1988). 

Clinical Treatment Issues 

Poverty is a significant barrier in obtaining 

health services, and this barrier is more

common for women than for men, especially in 

rural areas. Women in some segments of rural 

America perceive financial barriers to health 

care significantly more than men in rural areas 

and, consequently, experience poorer health 

than men (Beck et al. 1996b).

substance use disorders 

who live in rural areas 

may face a unique set 

of clinical issues that 

may challenge substance 

abuse professionals. 

These issues can include 

greater geographic 

and personal isolation, 

limited access to 

substance abuse 

treatment and mental 

health services (Ryland 

and Lucas 1996), 

poverty, and issues of 

confi dentiality. While 

rural women often face 

the same obstacles in 

obtaining substance 

abuse treatment services 

that challenge women 

anywhere, rural women 

are more likely to 

encounter a lack of child 

care, available treatment 

slots, transportation, 

and phone service, and 

possess a reluctance to 

address and disclose to 

staff (Tatum 1995). 

Treatment programs 

need to be culturally and 

ethnically appropriate 

for the community. 

Clinicians and other 

staff members may need 

to consider issues such 

as distance (e.g., how 

many miles from home to 

clinic), time and season 

 Women with 

Beyond the 

traditional therapy 

method used in 

many urban areas, 

the Appalachian 

tradition of 

storytelling has 

been used to help 

rural clients engage 

in treatment, gain 

insight into their 

problems, and 

learn new coping 

skills to address 

problems associated 

with substance use 

(Leukefeld et al. 

2000). 

Substance Abuse Among Specific Population Groups and Settings 131 
Advice to Clinicians and Administrators: 

Substance Abuse Treatment and Women in Rural Areas 

Clinical: 

• Screen for co-occurring disorders, and refer as needed.

• Obtain a history of traumatic events, including sexual abuse.

• Incorporate screening procedures to aid in appropriate referral to other health and

social services. 

• Explore potential reluctance in seeking help outside of immediate community. 

• Assess for a history of interpersonal violence, and recognize that rural women have

often reported learning that violence toward women is acceptable. 

• Explore beliefs and attitudes toward alcohol and drug use.

Program Development: 

• Develop partnerships among other local agencies and neighboring communities to

share resources to aid in the delivery of services in remote areas. 

• Develop a center that houses a network of services including health, mental health,

substance abuse, and other social services. 

• Develop a screening, assessment, and referral service for substance use disorders

within the Temporary Assistance to Needy Families (TANF) program. 

• Provide services that support substance abuse treatment attendance including child

care, transportation, and mobile treatment. 

• House support groups in the treatment facility, and consider providing or subsidizing 

transportation as a means of continuing care support. 

• Create professional training, network activities, and opportunities for staff to 

decrease feelings of isolation and staff turnover and to invest in workforce 

development. 

• Develop psychoeducational community programs to help reduce alcohol and nicotine

use during pregnancy. 

• Consider the use of telecounseling services in rural areas for assessment, pretreatment, counseling, and/or follow-up services. 

• Develop outreach services to address substance use and abuse issues among the aging

population of rural women. 

Staff Training: 

• Emphasize the prevalence of social shame among rural women who have substance

use disorders. 

• Discuss the cultural issues that may support a reluctance to seeking treatment outside

of the immediate community. 

• Review the challenges of anonymity in small communities, the strategies that can

enhance privacy, and the need to address and ensure confidentiality in treatment. 

• Examine the potential hidden attitudinal barriers among women seeking substance

abuse treatment including distrust of the “system,” expectation of failure, and 

positive beliefs regarding the benefits of alcohol and/or drug use. 

Source: Baca et al. 2007; Boyd 1998; 2003; CSAT 2003b; Howland 1995; Wilkins 2003. 

132 Substance Abuse Among Specific Population Groups and Settings 
(e.g., the demands of planting and harvesting, 

coordinating appointments with other trips to 

town), and even weather conditions to provide 

culturally acceptable services to rural clients 

(Bushy 1997). Another aspect of rural life is that 

communities are smaller and more close-knit 

so that everyone is familiar with the personal 

affairs of his or her neighbors. If, for example, 

a woman is arrested for driving under the 

influence, the chances are significant that the 

person in authority knows her or her family 

(Boyd 1998). Similarly, women in rural areas 

may know the law enforcement authority and, 

perhaps, know the substance abuse treatment 

provider as well. For rural women entering 

treatment who have been abused, their abusers 

may also be well known to the community. Prior 

reports of abuse may or may not be believed, 

and may set off counter-reactions against her. 

Women may wish to seek treatment outside the 

community, even if they have to travel long 

distances. They may choose not to be seen 

going to the counselor’s office or may have a 

preexisting relationship with the counselor. 

Conversely, women from rural communities 

may be reluctant to seek treatment outside of 

their communities, viewing treatment providers 

as “outsiders.” As to other identifi ed clinical 

issues among rural women with substance 

use disorders, the incidence of co-occurring 

disorders is suspiciously lower than among 

women from major metropolitan areas, perhaps 

because it is underdiagnosed and, as a result, 

undertreated (Kessler et al. 1994). 

Several treatment programs have been 

developed for use with rural residents. Among 

these is Structured Behavioral Outpatient Rural 

Therapy (SBORT), a cognitive–behavioral 

intensive outpatient approach consisting of two 

phases: pretreatment and treatment. The threesession pretreatment phase consists of individual 

counseling to increase readiness for change. 

The treatment phase involves 12 sessions in 6 

weeks and consists of storytelling and “thought 

mapping” to develop recovery skills (Clark et al. 

2002). Storytelling is used to encourage clients to 

share their experiences and to help them relate 

to the presenting material in treatment. During 

thought mapping, the group examines important 

incidents before and after prior use of alcohol 

or drugs. Treatment focuses on problemsolving 

strategies and other cognitive strategies, 

relaxation techniques, coping skills to deal with 

cravings, and encourages the utilization of selfhelp (Hall 1999). Specific outcome studies on 

SBORT for rural women in substance abuse 

treatment are lacking. 

Resiliency Factors 

In rural communities, there is typically a 

pattern of stability in residence, interpersonal 

relationships, and community. This stability can 

be a protective factor in recovery by providing 

sustained support. Likewise, large extended 

families, involvement in religious activities, 

and faith are attributes that are not only 

common in rural America but can serve as a 

conduit for treatment (Van Gundy 2006). From 

prevention to continuing care, counselors and 

administrators need to take advantage of these 

qualities in programming and clinical practice. 

Resources for Other 

Special Populations and 

Settings 

Women With Physical and 

Cognitive Disabilities 

Review TIP 29 Substance Use Disorder 

Treatment for People with Physical and 

Cognitive Disabilities. This is a practical 

resource for information on addressing 

treatment issues in this population (CSAT 

1998e). 

The 2000 Census reported that about 44 million 

noninstitutionalized adults have disabilities, 

including approximately 20 percent of adults 

younger than age 65 and 40 percent of those 

older than 65 (U.S. Census Bureau 2002). These 

individuals span all ages and racial, ethnic, and 

cultural backgrounds. One study (Larson et al. 

Substance Abuse Among Specific Population Groups and Settings 133 
2005) found that women with trauma histories 

and co-occurring substance use and mental 

disorders had high rates of physical disabilities, 

with the greatest number (15 percent) of 

disabilities being injury/musculoskeletal/ 

connective tissues problems. Although little 

research exists regarding the extent of combined 

disability and substance abuse, people with 

disabilities generally use substances at the same 

or higher rates than those without disabilities 

(CSAT 1994e). In some cases, the disability can 

exacerbate the risk factors for substance use 

disorders. 

Women with disabilities are affected by several 

factors that can increase the likelihood of 

substance abuse and dependence (Ferreyra 

2005): 

• 	Increased dependence on others for basic 

needs 

• 	Potential use of prescription medication for 

chronic pain 

• 	 Facilitation of substance use by family and 

friends to help cope with the disability 

• 	 Social isolation (lack of social support, 

unemployment, etc.) 

• 	Insufficient referral for substance abuse 

treatment by primary physician or caregiver 

caused by lack of recognition 

• 	Inaccessible substance abuse treatment 

programs 

Women in the Criminal 

Justice System 

Women in criminal justice facilities face 

numerous challenges including, but not limited 

to, greater health issues and higher prevalence 

of co-occurring disorders; increased likelihood 

Review TIP 44 Substance Abuse Treatment 

for Adults in the Criminal Justice System. 

This is a practical resource for information 

on addressing treatment issues in this setting 

(CSAT 2005c) 

of pregnancy and need for prenatal care; 

history of sexual violence and other forms of 

abuse; and childcare, custody, and parenting 

issues. The number of female inmates in all 

criminal justice facilities has been increasing at 

a faster rate than the number of male inmates. 

Between 1995 and 2002, the average annual 

growth rate of incarcerated females was 5.4 

percent, compared with 3.6 percent for males 

(Harrison and Karberg 2003). Among the prison 

population, from 1990 to mid-2001, the number 

of female inmates jumped 114 percent; the 

male population grew by 80 percent in the same 

period (Beck et al. 2002). African Americans 

and Hispanics/Latinas account for nearly twothirds of incarcerated women. Their median 

age is in the 30s. Nearly half of those in State 

prisons and other correctional facilities have 

never been married (Greenfeld and Snell 1999). 

Among State prisoners, females were more likely 

than males to be sentenced for drug offenses (29 

percent versus 19 percent; Sabol et al. 2007). 

Among Federal defendants in 2004, the leading 

drug arrests and sentences among women were 

related to methamphetamine (Bureau of Justice 

Statistics 2004). Women were more likely than 

men to have used methamphetamines in the 

month before their offense (Bureau of Justice 

Statistics 2006). According to U.S. Department 

of Justice, an estimated 52 percent of females in 

comparison to 44 percent of males incarcerated 

in local jails were dependent on or abusing 

drugs. In the last decade, more than half of 

all female prisoners reported being under the 

influence of alcohol or drugs at the time they 

committed the crime, with drug use being 

more prevalent (Greenfield and Snell 1999). In 

addition to TIP 44 Substance Abuse Treatment 

for Adults in the Criminal Justice System (CSAT 

2005c), refer to Gender-Responsive Strategies: 

Research, Practice, and Guiding Principles for 

Women Offenders (Bloom, Owen, and Covington 

2003) for more information. 

134 Substance Abuse Among Specific Population Groups and Settings 
Women Who Are 

Homeless 

Review the planned TIP Substance Abuse 

Treatment for People Who Are Homeless. 

This TIP is a practical resource for 

information on addressing treatment issues 

in this setting (CSAT in development g). 

According to the Annual Homeless Assessment 

Report to Congress (2008), nearly 3 percent of 

Americans experience homelessness at any one 

time. Approximately 23 percent are chronically 

homeless with homelessness disproportionately 

affecting African Americans (44 percent of 

the total homeless population). Less is known 

about homeless women. Data collections often 

have missing personal identifiers, leading to less 

than reliable estimates of homeless women and 

homeless women and their children. 

In exploring factors associated with women who 

are homeless (literal definition of homelessness: 

sleeping in shelters, public places, abandoned 

buildings, etc.), literature suggests signifi cantly 

higher prevalence rates of domestic violence and 

serious health problems including HIV. Most 

women who are homeless do not have a criminal 

record. Nearly half never lived independently 

prior to losing their housing arrangement, and 

that housing arrangement mainly disintegrated 

between the woman and extended family 

members, spouse, or significant other. More 

than 25 percent reported loss of employment 

as the immediate cause of homelessness, while 

another 25 percent of women reported domestic 

violence as the cause (Levin et al. 2004). Other 

factors that contribute to homelessness include 

illness, recent relocation (Lehmann et al. 2007), 

hospitalization, severe mental illness, substance 

use disorders, high-risk pregnancy, increased 

rents, or fire (SAMHSA 2003b; Levin et al. 

2004). The majority of women who are homeless 

using shelters have children (83 percent; HUD 

2008). It is estimated that 84 percent of homeless 

adults with families are women (AHAR 2007). 

Substance abuse among women 

who are homeless 

Alcohol abuse and drug use has increased among 

homeless women in the past 20 years (North 

et al. 2004). Numerous studies (Koegel et al. 

1999; North et al. 2004a; Robertson et al.1997) 

provide estimates on lifetime and current 

substance use disorders among homeless women 

with lifetime estimates ranging from 56 to 63 

percent and current estimates spanning 38 to 58 

percent. Twenty percent of homeless admissions 

to substance abuse treatment are women, with 

admission rates higher among African-American 

women. Upon admission, prevalence rates of 

alcohol-related admissions were similar to all 

female admissions, while prevalence of cocaine/ 

crack and heroin were more likely reported 

among homeless women (OAS 2004a). 

SAMHSA offers a Homelessness Resource Center, a virtual community located at www. 

homeless.samhsa.gov. For providers who serve the homeless, this site offers information on a 

wide range of programmatic and clinical topics, provides access to related resources, including 

a one-stop site for all Federal Government materials on homelessness, and provides a place to 

share ideas and to gain support. 

Substance Abuse Among Specific Population Groups and Settings 135 
In This
 

Chapter
 

Treatment Retention
 

Women’s Treatment 


Issues and Needs
 

Addressing Tobacco 


Use With Women 


in Treatment
 

7 Substance Abuse 

Treatment for Women 

Overview 

While women are as likely to stay and engage in treatment as men, 

substance abuse counselors need to attend to individual, counselor, 

and environmental variables to secure the best retention rates based 

on level of care and presenting problems. This chapter begins with 

gender-specific factors that signifi cantly influence treatment retention 

of women. Other highlights include women’s treatment issues and 

needs (beginning with the role of relationships—including family and 

partners), parenting issues and treatment needs (including pregnancy 

and children), and several co-occurring disorders (including anxiety, 

mood, and eating disorders) that are most prevalent among women 

and are likely to require attention during the course of treatment. 

Significant consideration is also given to trauma, trauma-informed 

services, and integrated treatment for women with trauma-related 

symptoms and substance use disorders. 

Treatment Retention 

The many factors that influence clients to enter treatment are often 

the same ones that keep them in treatment. Treatment retention refers 

to the quantity or amount of treatment received by a client. Today, 

retention is more likely defined using the term “length of stay,” and 

is measured by months or a timeframe rather than by the number of 

sessions (Comfort and Kaltenbach 2000; Greenfield et al. 2007a). Historically, literature has reflected that treatment duration (retention) 

has served as one of the most consistent predictors of posttreatment 

outcome, yet literature remains limited regarding the specifi c relationship between retention and outcome among women with substance use 

disorders. (For literature reviews on retention and outcome factors 

for women with substance use disorders, see Sun 2006; Greenfi eld et 

al. 2007a.) 

Substance Abuse Treatment for Women 137 
Gender is not likely to predict retention in 

substance abuse treatment. For some time, it 

has been assumed that women are more likely 

to leave treatment, but some literature counters 

this view (Joe et al. 1999). Do women have lower 

retention rates than men? This is a diffi cult 

question to answer because treatment retention 

often involves the contribution and interaction 

of numerous variables. Studies have begun to 

identify these variables and how they relate 

to each other to influence treatment retention 

rates among women (see Ashley et al. 2004), but 

further research is needed to understand the 

complexity and interactions of these variables. 

Psychiatric symptoms, drugs of choice, 

motivation levels, class, race, ethnicity, 

criminal justice history, addiction severity, 

and patterns of use are common factors that 

typically influence or predict retention among 

clients in general (see Simpson 1997). Among 

women, several factors have been identifi ed that 

influence or predict retention. The following 

section highlights these factors. Nonetheless, this 

is not an exhaustive list of retention conditions 

or issues, but one that is limited to factors 

that are evident across several studies or that 

provide some insight into women’s issues that 

need further empirical exploration. 

Factors That Infl uence Retention 

Among Women 

Sociodemographics 

Relationships: Support from a partner 

during treatment and recovery can contribute 

significantly to long-term maintenance of 

abstinence. Some treatment studies suggest that 

including a partner or significant other in a 

client’s treatment also contributes signifi cantly 

to successful short-term outcomes (Price and 

Simmel 2002). For example, couples therapy 

for women in alcohol and drug abuse treatment 

contributed to favorable outcomes in one study 

(Trepper et al. 2000), and a study by FalsStewart and colleagues (2005) indicates that 

behavioral couples therapy was associated with 

abstinence and sustained recovery. Zlotnick 

and colleagues (1996) also found family therapy 

to be an effective component for women in an 

outpatient substance abuse treatment program. 

It appears that women who develop 

relationships in treatment are less likely 

to successfully complete treatment if their 

new partner discontinues treatment. In one 

qualitative study, all of the women who did not 

successfully complete treatment established a 

sexual relationship during the early phase of 

outpatient treatment (Ravndal and Vaglum 

1994). 

Age: Age appears to be a factor that infl uences 

retention. According to the Drug Abuse 

Treatment Outcome Study (DATOS), age has 

a significant positive effect on retention in 

residential treatment (Grella et al. 2000). In 

a study examining variables associated with 

retention in outpatient services, women younger 

than 21 were not as likely to successfully 

complete outpatient treatment (Scott-Lennox 

et al. 2000). Likewise, criminal justice research 

found that women who are older at their fi rst 

arrest were more likely to complete treatment 

(Pelissier 2004). 

Education: Women with a high school education 

are more likely to stay in treatment. According 

to two studies (Ashley et al. 2004; Knight 

et al. 2001), women who have a high school 

degree or equivalent are more likely to stay in 

treatment longer and complete treatment than 

women with less than a high school education. 

While education level is influential, it may be 

a reflection of other client characteristics or 

socioeconomic conditions. 

Women of color: Research typically refl ects 

lower retention rates among women of color. 

While more research is needed to pinpoint the 

specific factors that lead to lower retention rates 

among ethnically diverse women, a key variable 

appears to be economic resources. According 

to Jacobson, Robinson, and Bluthenthal 

(2007), limited economic resources may play a 

more significant role in retention than specifi c 

demographics or severity of substance use 

disorder. 

138 Substance Abuse Treatment for Women 
Criminal justice and child 

protective services referral and 

involvement 

It appears that either referral or involvement 

with the criminal justice system or child 

protective services is associated with longer 

lengths of treatment (Brady and Ashley 2005; 

Chen et al. 2004; Green et al. 2002). Specifi cally, 

Nishimoto and Roberts (2001) concluded that 

women who were mandated by the criminal 

justice system to enter treatment and who also 

had custody of their children were more likely 

to stay in treatment longer. While some studies 

reflect mixed results on the effect of women 

being mandated to treatment by the court, 

another study (generated from the sample of 

participants in the Substance Abuse and Mental 

Health Services Administration’s [SAMHSA’s] 

Women, Co-Occurring Disorders, and Violence 

Study) found that retention was higher among 

women who had been mandated to treatment 

(Amaro et al. 2007). 

Pregnancy 

Pregnancy status can signifi cantly infl uence 

treatment engagement and retention. Grella 

(1999) concluded that pregnant women were 

more likely to spend less time in treatment, and 

that pregnancy interrupted treatment. Yet, the 

length of stay may be more related to the stage 

of pregnancy. In another retention study among 

women, women who entered treatment late in 

their pregnancies had good retention whereas 

women who entered treatment in their fi rst 

trimester tended to leave treatment early (Chen 

et al. 2004). 

Pregnancy and co-occurring disorders: 

Pregnancy often adds to the challenge of 

retaining clients who have severe psychiatric 

disorders in treatment. In one study (Haller 

et al. 2002) that compared retention rates 

across three groups of women, the group 

characterized by severe addiction, psychiatric 

(DSM Axis 1 diagnosis) and personality (DSM 

Axis 2 diagnosis) disorders had rapid attrition 

(a 36 percent dropout rate), whereas the 

groups described as clinically benign or with 

less severity but with externalizing personality 

deficits were more likely to complete treatment. 

In a similar study conducted by Haller and Miles 

(2004), women with more severe pathology were 

twice as likely to leave treatment against medical 

advice. While these studies have limitations, 

they do shed light on the role of psychiatric 

issues in retention among women, particularly 

pregnant women, and the need to provide 

appropriate intervention earlier in the treatment 

process. The findings of a study examining the 

effects of trauma-integrated services suggest that 

women who receive these mental health services 

may engage in treatment longer (Amaro et al. 

2008). 

Treatment environment and 

theoretical approach 

Supportive therapy: The consensus panel’s 

clinical experience has shown that women who 

abuse substances benefit more from supportive 

therapies than from other types of therapeutic 

approaches. Review of the literature indicates 

that positive treatment outcomes for women 

are associated with variables related to the 

characteristics of the therapist (e.g., warmth, 

empathy, the ability to stay connected during 

treatment crises, and the ability to manage 

countertransference during therapy; Beutler et 

al. 1994; Cramer 2002; Crits-Christoph et al. 

1991). Women need a treatment environment 

that is supportive, safe, and nurturing 

(Cohen 2000; Grosenick and Hatmaker 2000; 

Finkelstein et al. 1997); the therapeutic 

relationship should be one of mutual respect, 

empathy, and compassion (Covington 2002b). 

The type of confrontation used in traditional 

programs tends to be ineffective for women 

unless a trusting, therapeutic relationship has 

been developed (Drabble 1996). Early research 

on women in treatment demonstrated that 

women entered treatment with lower self-esteem 

than their male counterparts (Beckman 1994). 

Hence, the traditional practice during recovery 

of “breaking down” a person who abuses 

substances and rebuilding her as a person is 

considered unduly harsh and not conducive 

to effecting change among women who abuse 

substances (Covington 2008a rev., 1999a; 

Drabble 1996; Kasl 1992). Although designed 

Substance Abuse Treatment for Women 139 
to break through a client’s denial, these 

approaches can diminish a woman’s self-esteem 

further and, in some cases, retraumatize her. 

Approaches based on awareness, understanding, 

and trust are less aggressive and more likely to 

effect change (Miller and Rollnick 2002). An 

atmosphere of acceptance, hope, and support 

creates the foundation women need to work 

through challenges productively. 

Collaborative approach: Leading practitioners 

in the field of substance abuse treatment for 

women suggest that effective therapeutic styles 

are best characterized as active, constructive, 

collaboratively and productively challenging, 

supportive, and optimistic (Covington and 

Surrey 1997; Finkelstein 1993, 1996; Miller 

and Rollnick 1991). Effective therapeutic styles 

focus on treatment goals that are important to 

the client. This may mean addressing issues of 

food, housing, or transportation fi rst. Having 

her primary needs met builds a woman’s trust 

and allows her to address her substance use. A 

collaborative, supportive approach builds on 

the client’s strengths, encourages her to use her 

strengths, and increases her confidence in her 

ability to identify and resolve problems. 

Effective therapeutic styles facilitate the client’s 

awareness of the difference between the way her 

life is now and the way she wants it to be. The 

client and counselor agree to work together to 

identify the client’s distortions in thinking— 

discrepancies between what is important 

to her and how her behavior and coping 

mechanisms prevent her from reaching her 

goals. Approaching treatment as a collaboration 

between equal partners—where the therapist 

is the expert on what has helped other people 

and the client is the expert on what will work for 

herself—may reduce the client’s resistance to 

change. 

Type of treatment services 

Same-sex versus mix-gender groups: While 

literature (Grella 1999; Gutierres and Todd 

1997; Niv and Hser 2007; Roberts and 

Nishimoto 1996; Zilberman et al. 2003) generally 

supports same-sex groups as being more 

beneficial than mix-gender groups for women, 

most research surrounding this issue is either 

too small to generalize, fails to control for 

other factors that may influence results, or falls 

short in matching and evaluating same-sex and 

mix-gender groups using comparable services 

and program lengths. Inconsistent results are 

evident when comparing retention and outcome 

rates between both groups (Kaskutas et al. 

2005). Historically, research has not controlled 

for the confounding variable that female-only 

groups provide more gender-responsive services 

than mix-gender groups. These enhanced 

services may be more responsible for retention 

and outcome than the gender constellation of 

treatment. In one study comparing women in 

a female-only program to a mix-gender group, 

the author concluded that just placing women 

in a same-sex group without women-specifi c 

treatment services is not effective in improving 

retention or outcome (Bride 2001). 

More rigorous studies are needed to clarify 

factors. Several qualitative studies (Grosenick 

and Hatmaker 2000; Nelson-Zlupko et al. 1996; 

Ravndal and Vaglum 1994) have highlighted that 

women perceive same-sex or female-only groups 

as more beneficial than mix-gender groups 

Note to Clinicians 

While women may perceive female-only groups as beneficial, it is important for clinicians to 

prepare for and recognize that some women may express hostility toward other women in the 

group or treatment program. Women are as likely to impose the same societal gender stereotypes 

that they experience onto other women in the group (Cowan and Ullman 2006). Some women 

may see other women as a threat to their relationships and engage in competitive behavior in the 

group process, and other women may impose and project their internalized negative stereotypes 

onto other group members; e.g., blaming a woman who was victimized by violence or making 

assumptions about, calling attention to, or labeling another woman’s sexual behavior. 

140 Substance Abuse Treatment for Women 
because they provide the women more freedom 

to talk about difficult topics such as abuse and 

relationship issues and to focus on themselves 

rather than on the men in the group. TIP 41 

Substance Abuse Treatment: Group Therapy 

(CSAT 2005d), provides more information 

on treatment issues and process using group 

therapy. 

Service delivery: Women who have access 

to various services in one location appear to 

have higher retention rates (McMurtrie et 

al. 1999; Volpicelli et al. 2000). In addition, 

studies support that women who are involved 

in or initially receive greater intensive care, 

specifically residential treatment, are more 

likely to remain in treatment and in continuing 

care (Coughey et al. 1998; Strantz and Welch 

1995). Retention is also heightened when 

treatment services also include individual 

counseling for women (Nelson-Zlupko et al. 

1996). 

Onsite child care and child services: In two 

randomized studies (Hughes et al. 1995; 

Stevens and Patton 1998) comparing women in 

residential programs whose children stayed with 

them versus women whose children did not stay 

with them, women whose children stayed with 

them had a longer length of stay (retention). 

Other less rigorous studies provide similar 

results (Ashley et al. 2004; Metsch et al. 2001; 

Nelson-Zlupko et al. 1996; Wobie et al. 1997). 

For more information on children in residential 

treatment programs, see chapter 5, “Treatment 

Engagement, Placement, and Planning.” 

Therapeutic alliance and counselor 

characteristics 

Although the relationship with the counselor is 

important to both men and women, each gender 

defines this connection differently. When women 

and men were asked what was important about 

the quality of their therapeutic relationships 

and their recovery from substance abuse, most 

women answered trust and warmth, and most 

men answered a utilitarian problemsolving 

approach (Fiorentine and Anglin 1997). Across 

studies, women have identified several counselor 

characteristics they believe contribute to 

treatment success: non-authoritarian attitudes 

and approach, confidence and faith in their 

abilities, and projection of acceptance and care 

(Sun 2006). Overall, the therapeutic alliance 

appears to play a paramount role in predicting 

posttreatment outcome (Gehart and Lyle 2001; 

Joe et al. 2001; Miller et al. 1997). 

Staff gender: Research on the impact of gender 

differences in client–counselor relationships is 

limited across mental health professions and 

is nearly non-existent in the substance abuse 

field. Although women show greater preference 

for female staff in addiction treatment, 

further research is needed in examining the 

role of gender in treatment retention and 

outcome among women in individual versus 

group counseling, same-sex versus mix-gender 

groups and treatment programs, and women at 

different levels of substance abuse treatment. In 

a study that examined how clients in inpatient 

substance abuse treatment would view their 

ideal male and female counselor, gender was 

not considered an important variable even 

Implications for the Male Counselor 

“Men may need to pay particular attention to certain issues when counseling women. The issues 

of anger, autonomy, power, and stereotypical roles have great impact on women clients and 

are extremely important issues for women in therapy. For some women, because of previous 

dependence on men, their emotional responses to anger are more likely to be repressed and 

viewed as unacceptable. For other women, autonomy and power are often seen as masculine 

traits and inappropriate for women. Men’s greater, or perhaps different, familiarity with anger, 

autonomy, and power can potentially provide therapeutic benefit for their women clients” (DeVoe 

1990, p. 33). 

Substance Abuse Treatment for Women 141 
Improving Transitions and Retention Rates for Women 

Programs that maintain relationships or connections with women throughout their treatment and 

during step-down transitions from more intensive to less intensive treatment appear paramount 

in maintaining high levels of retention. Using supportive telephone calls between residential and 

outpatient addiction treatment is an effective strategy for women. Women are more likely than 

men to attend continuing care if a telephone intervention is implemented (Carter et al. 2008). In 

addition, women are more likely to stay in treatment during transitions to less intensive levels of 

care if it is the same treatment agency (Scott-Lennox et al. 2000). 

though the majority of clients preferred a 

female therapist (Jonker et al. 2000). Prior 

research on therapist preference in counseling 

highlighted that nearly 95 percent of women 

who expressed a preference specified a female 

counselor (Stamler et al. 1991). Grosenick and 

Hatmaker (2000) reported that 82 percent of 

the women and treatment staff in a residential 

program treating pregnant women and women 

with children believed it was important to have 

female staff, while 38 percent of the clients and 

46 percent of the staff sample asserted that male 

staff were important. For those who endorsed 

the importance of male staff, they indicated that 

men serve as male role models for children and 

provide a male perspective on various clinical 

issues, such as relationships. 

In a study that examined the influence of both 

client–counselor race and gender composition 

in treatment retention among African-American 

clients in intensive outpatient groups (Sterling 

et al. 1998), no significant gender differences 

were found. Nonetheless, several trends were 

evident. Female clients treated by female 

counselors stayed in treatment 5 days longer 

than mix-matched gender groups (mix-matched 

refers to clients being matched to counselors 

of the opposite sex), and women in gendermatched groups at discharge were more likely to 

continue outpatient care. The authors suggested 

that different results may have transpired if 

they had examined the role of gender and race 

in client–counselor relationships in individual 

substance abuse counseling versus group 

therapy. Research focused specifi cally on 

client–counselor race and gender composition in 

women’s treatment is lacking. 

Client’s confidence in the process 

A woman’s successful experience in other 

life areas and her level of confidence in the 

treatment process appear important to staying 

in treatment. Kelly, Blacksin, and Mason (2001) 

compared two groups of women—a group that 

completed treatment and another group that 

did not—to ascertain factors affecting substance 

abuse treatment completion. They found that 

women who had prior successes were more apt 

to complete treatment. While self-effi cacy may 

play an important role, methodological issues 

and other factors may be as responsible for the 

study’s results, namely the limited economic 

resources in the group of non-completers. In 

addition, other general retention studies have 

highlighted the importance of the therapist’s 

prognosis of client retention; thus the 

counselor’s confidence may be as signifi cant to 

retention as the client’s confi dence (Cournoyer 

et al. 2007). Further gender-specifi c retention 

research is needed to address the role of selfconfidence and confidence in the treatment 

process. 

Theoretical Approaches 

for Women 

In a meta-analysis of studies on treatment 

approaches, Wampold (2001) attributed 

more than half of the effect of therapies to 

therapeutic alliance—a key element of all the 

theoretical approaches. Some approaches have 

significant clinical and empirical support in 

substance abuse treatment research literature 

(including motivational interviewing, cognitive– 

behavioral therapies, and some psychodynamic 

142 Substance Abuse Treatment for Women 
approaches), however, research highlighting 

the role of gender differences is in its infancy, 

and limited research is available that delineates 

gender-specific factors that contribute to the 

effectiveness of these therapies. Data available 

at the time of publication is referenced 

throughout this TIP. For general information 

on counseling theories, refer to TIP 34 Brief 

Interventions and Brief Therapies for Substance 

Abuse (CSAT 1999a); TIP 35 Enhancing 

Motivation for Change in Substance Abuse 

Treatment (CSAT 1999b); and TIP 47 Substance 

Abuse: Clinical Issues in Intensive Outpatient 

Treatment (provides an overview of counseling 

theories; CSAT 2006c). 

Women’s Treatment Issues 

and Needs 

Relationships and the Need for 

Connection 

Relationships are central in women’s lives—as 

part of their identities, as sources of self-esteem, 

as the context for decisionmaking and choices, 

and as support for day-to-day living and growth 

(Covington and Surrey 1997; Finkelstein 

1993, 1996; Miller 1984). Connections are 

relationships that are healthy and supportive— 

mutual, empowering, and emotional resources. 

“Disconnections” involve relationships that 

are not mutual and empowering: one member 

is dominant, there is imbalance in the give 

and take, or a disparity exists in emotional 

supportiveness. Disconnections range from 

feeling “unheard” or “unknown” to extreme 

forms of disconnection, such as sexual abuse 

and violence. Disconnections create major 

difficulties for most women, such as lowered 

self-esteem, feelings of powerlessness, and lack 

of assertiveness. The experience of relationships 

as connections and disconnections is a central 

issue in personality development, with repeated 

severe disconnections potentially having serious 

psychological and behavioral consequences. 

The Influence of Family 

Treatment providers should be sensitive to the 

relational history women bring into treatment, 

both positive and negative. For instance, the 

extended family often functions as a safety net 

that provides women with child care, fi nancial 

support, and emotional and spiritual guidance 

(Balcazar and Qian 2000). However, few 

studies have examined the role of the extended 

family in the development of substance abuse 

and recovery. While research on the extended 

family tends to define its role as primarily 

protective, drinking and drug use in the family 

can contribute to the development of abuse. 

Many women who abuse substances were raised 

in families where there was chemical abuse, 

sexual abuse, violence, and other relational 

disconnections. These family relationships form 

a basic model for the relationships women later 

develop with others. 

Women with a substance-using family 

background may develop adult relationships 

that mimic these broken family dynamics. Thus 

many women who have family members who 

used substances also may have a partner or 

friend who abuses substances. Relationships 

that center on substance use, or include 

emotionally or physically negative, harmful 

behavior (whether past or present), can play a 

significant role in enabling a woman’s continuing 

substance use. 

To assess the impact of a client’s family 

relationships, treatment providers should 

explore the role of the extended family in her 

life and try to determine how her substance 

abuse has affected her relationships with family 

members. Counselors should also help a client 

to explore her current relationships outside 

her family in the light of her substance use. 

Counselors may need to work with some clients 

to help them understand the negative effects 

these relationships can have. 

In addition, skills related to improving the quality 

of relationships—such as communication, stress 

management, assertiveness, problemsolving, 

and parenting—can be an important part of 

treatment. To help clients learn these skills, 

Substance Abuse Treatment for Women 143 
treatment providers can model connection with 

clients, provide support, help clients repair or 

replace hurtful or damaging relationships, and 

help clients “redefine” their families (Knight et 

al. 2001b). Family therapy is a more essential 

approach in substance abuse treatment for 

women. For more guidance in employing family 

therapy, refer to TIP 39 Substance Abuse 

Treatment and Family Therapy (CSAT 2004b). 

If maintaining or reconnecting with extended 

family members is not an option, plans should 

be made to find alternatives in developing 

a support system or a “family of choice.” 

However, the grief associated with the loss of the 

original family needs to be addressed. Treatment 

programs can help women connect with natural 

supports in the community—friends, work 

colleagues, and significant others (Knight and 

Simpson 1996). Developing or maintaining 

Advice to Clinicians: 

Relational Model Approach 

Beginning in the 1970s, a number of theorists started to examine the importance 

of gender differences in psychological development. Jean Baker Miller’s Toward a 

New Psychology of Women (1976) offered a new perspective on the psychology of 

women that challenged the basic assumptions of traditional theories. Carol Gilligan, a 

developmental psychologist, gathered empirical data on fundamental gender differences 

in the psychological and moral development of women and men (Gilligan 1982). 

Drawing on Miller’s and Gilligan’s work, theorists have been developing a relational 

model of women’s psychology. The three major themes in relational theory are: 

• 	 Cultural context. Recognizes the powerful effect of the cultural context on women’s 

lives. 

• 	 Relationships. Stresses relationships as the central organizing feature in women’s 

development. Traditional developmental models of growth emphasize independence 

and autonomy. This model focuses on women’s connection with others. 

• 	 Pathways to growth. Acknowledges women’s relational qualities and activities as 

potential strengths that provide pathways to healthy growth and development. 

The relational-cultural theory affirms the power of connection and the pain of 

disconnection for women, with repeated disconnections having adverse consequences 

for mental health (Covington and Surrey 1997; Jordon and Hartling 2002). As a result, 

the approach requires a paradigm shift that has led to a reframing of key concepts in 

psychological development, theory, and practice. For example, instead of using the “self” 

as the sole focus, the model focuses on relational development. 

According to Miller, “Women’s sense of self becomes very much organized around being 

able to make and then to maintain affiliations and relationships” (Miller 1984, p. 83). 

More than men, women find an activity more satisfying and more pleasurable when 

others are involved. Therefore, for women, relationships directly affect their feelings of 

empowerment, self-worth, and self-esteem. 

Substance abuse treatment often provides a woman her first opportunity to establish 

new, healthy relationships—especially relationships with other women. Accordingly, 

counselors should help women to “examine past relationships, including issues of loss, 

violence, and incest; to validate and build upon [their] relational skills and needs; to 

learn how to parent successfully; ...to let go of problematic, abusive relationships” 

(Finkelstein 1996, p. 28); and to confront the loss of a primary relationship with their 

drug of abuse (Cramer 2002). 

144 Substance Abuse Treatment for Women 
positive relationships can improve women’s selfesteem and increase their feelings of self-effi cacy 

(Finkelstein et al. 1997). Further, a high degree 

of social support is positively related to better 

treatment outcomes (Laudet et al. 1999). 

Partner Relationships 

Many women drink and use substances to 

maintain relationships and cope with the pain 

and trauma of lost relationships. Some women 

feel they are expected to maintain relationships 

at all costs, even if those relationships are 

undermining, abusive, or otherwise detrimental. 

Women may stay in harmful relationships 

because of economic or social dependence. 

Treatment providers sometimes unknowingly 

reinforce this expectation by focusing on the 

importance of relationships to the exclusion of 

helping their clients increase their feelings of 

autonomy, healthy solitude, and individuality— 

also important needs for women. 

Once a woman’s significant relationships have 

been examined relative to her substance use, the 

counselor and client can work together on a plan 

for reconnecting with significant others during 

recovery (if possible). Yet, engaging a partner 

in a woman’s treatment can be challenging, 

especially in balancing issues of the woman’s and 

her partner’s needs, safety concerns, and lack 

of funding for partner and family services. Few 

models within women’s treatment programs exist 

that include partners and other family members, 

and even fewer address lesbian partners. Price 

and Simmel (2002) provide an overview of the 

issues surrounding a partner’s influence on a 

woman’s addiction and recovery and examples 

of model programs. They recommend starting 

with a thorough assessment after a woman has 

identified her partner(s) and given permission to 

involve the partner in treatment. 

As women become healthy through participating 

in treatment and developing appropriate 

relationships, and as other supports (e.g., 

financial, housing) are put in place, it is hoped 

they will choose to reevaluate relationships 

that are detrimental to their well-being and 

recovery. When women decide to end signifi cant 

relationships, counselors should realize that 

ending these significant relationships is a 

real loss that must be mourned while new 

attachments are being created. However, some 

women often choose to continue to participate 

in, or may be unable to escape, destructive 

relationships. 

Tolerating or accepting a client’s relationships 

that the counselor finds objectionable is 

complicated because a woman’s substance abuse 

frequently is maintained in connection with 

her partner (Amaro and Hardy-Fanta 1995), 

and maintaining this relationship can increase 

her risk of relapse. Thus, any relationship that 

enables a woman to continue to abuse substances 

or threatens her safety becomes a therapeutic 

issue between a counselor and a female client. 

The counselor should acknowledge a woman’s 

feelings about that relationship, regardless of 

the counselor’s opinion about what is best for 

the client. However, if a client is in danger of 

being victimized, the counselor should primarily 

be focused on ensuring her safety. Initially, staff 

should take immediate measures to increase 

physical safety in the treatment environment— 

in both outpatient and inpatient settings. 

In addition to validating her experience, it 

is important to help facilitate a safety plan 

that may necessitate additional referrals to 

domestic violence hotlines and shelters. To 

review a sample personalized safety plan for 

domestic violence, refer to Appendix D in TIP 

25 Substance Abuse Treatment and Domestic 

Violence (CSAT 1997b). 

Safety issues for the client or her children may 

preclude the partner’s involvement. If the client 

does not feel safe involving her partner, the 

emphasis should change to safety planning. 

Several curricula focus on a woman’s 

relationships in recovery and help her 

identify, assess, and evaluate both destructive 

and empowering relationships and support 

systems. Covington’s curriculum, Helping 

Women Recover (2008a, 1999a), allows women 

to examine their relationships and support 

systems. Najavits’ Seeking Safety (2002a) and 

Woman’s Addiction Workbook (2002) include 

information that assists women in understanding 

healthy and unhealthy boundaries, strategies 

Substance Abuse Treatment for Women 145 
Advice to Clinicians: 

Considerations in Involving the Partner in Treatment 

In deciding whether or not to involve a woman’s partner in treatment, primary 

consideration should be given to her safety and to the partner’s willingness to 

participate in treatment. The following important issues should also be assessed 

to determine participation and level of treatment involvement and to establish an 

appropriate treatment plan: 

• 	 History of violence: Has there been a history of violence in the relationship, including 

threats and other emotional, physical, and/or sexual abuse; protection orders; police 

reports; or citations for domestic violence or assaults? Is there a history of impulsivity 

with client or partner? Has there been a history of violence outside the relationship, 

in previous relationships, or with children? Is there a recognizable progression of 

violence in the relationship? 

• 	 History of substance use in the relationship: How influential has this partner been 

regarding the client’s continued drug and alcohol use? Does the partner see the 

woman’s alcohol and/or drug use as a problem needing treatment? Has the history 

of the relationship been centered upon using or providing drugs and alcohol? 

How often are alcohol and other drugs used when engaged in activities with each 

other or during sexual intimacy? Is the client or partner worried about having sex 

without being under the influence of substances? Has the client left prior treatment 

experiences prematurely due to this relationship? Is the client worried that her 

partner is going to leave either as a result of her use or of her treatment? Does the 

client acknowledge that her use has impacted the relationship? Is she able to describe 

how her substance use has affected the relationship? 

• 	 Partner’s history of substance use: What is the partner’s attitude toward alcohol 

and drug use? Does he/she use as well? Is he/she in recovery? Has the partner been 

arrested, charged, or convicted of alcohol or drug related offenses? Does the client 

minimize the influence of her partner’s current drug and alcohol use? 

• 	 Accessibility: Does the partner have the financial resources and transportation to 

attend treatment? Are there potential barriers that limit physical attendance, such as 

distance from program, transportation, work schedule, financial resources, childcare 

responsibilities? 

• 	 History of mental illness: Are there any known mental health issues with the partner 

or client that have or will impact the relationship? 

• 	 Relationship support of the partner: Has the partner been emotionally supportive 

throughout the history of the relationship? Currently, how emotionally supportive 

is the partner regarding the client’s treatment and recovery? Does the partner play 

an essential role in childcare? Does the partner provide financial support? Has the 

partner ever threatened to leave, withdraw financial support, or threaten the custody 

of the children? 

• 	 Commitment to relationship: Is there a current commitment to maintaining the 

relationship? 

146 Substance Abuse Treatment for Women 
Substance Abuse Treatment for Women 147

for identifying persons who can be positive 

(supportive) or negative (destructive) infl uences 

on their recovery, tactics for enhancing or 

minimizing those infl uences, and activities to 

enhance support from other women. Cohen’s 

Counseling Addicted Women: A Practical 

Guide (2000) provides client and staff activities 

surrounding relationship issues.

Sexuality

Healthy sexuality is integral to one’s sense of 

self-worth. Sexuality represents the integration of 

biological, emotional, social, and spiritual aspects 

of who one is and how one relates to others. If 

healthy sexuality is defi ned as the integration 

of all these aspects of the self, it is apparent 

how substance abuse can have an impact on 

every area of a woman’s sexuality. In addition, 

sexuality is one of the primary areas that women 

say change the most between substance abuse or 

dependence and recovery and is a major trigger 

for relapse (Covington 2008a, 1999a, 2007).

Women and men are socialized into different 

gender roles. For example, many men are 

taught to seem knowledgeable about sex and 

be comfortable with their bodies. In contrast, 

women struggle more with body image and are 

socialized to be less assertive sexually or risk 

being labeled as promiscuous. This polarization 

of sex roles is mirrored in society’s belief about 

male and female substance use. Women who use 

substances are perceived as being more eager for 

sex and more vulnerable to seduction (George et 

al. 1988). This is refl ected in the stronger stigma 

against women with substance use disorders, 

which is often expressed in sexual terms and 

labels women as promiscuous or sexually loose. 

Sexual terms are rarely used to describe men 

with substance use disorders.

Recovery and healing goes beyond abstinence 

from alcohol or drugs to developing 

relationships with others. Many women will need 

to explore the connections between substance 

abuse and sexuality, body image, sexual identity, 

sexual abuse, and the fear of sex when they are 

alcohol and drug free. Therefore, the consensus 

panel believes that discussion of women’s 

sexual issues is an important part of substance 

abuse treatment. The following are some of the 

sexual concerns that women report during early 

recovery:

• Sexual identity. Counselors may need to 

help a woman determine her sexual identity 

as a heterosexual, lesbian, or bisexual 

person. Substance abuse during adolescence 

can interrupt the healthy development 

of sexual identity. Circumstances such as 

prostitution or incarceration may lead 

women to participate in sexual activity with 

other women. Some women use drugs to 

suppress their sexual feelings toward other 

women. Others use drugs to act on their 

erotic attachment to other women and may 

feel confused about their sexual identity 

when in recovery. Once the substance of 

abuse has been removed from a woman’s 

life, the counselor can help her discover 

whether her identity is heterosexual, lesbian, 

or bisexual (Covington 1997). For review of 

sexual identity stages of development and 

its relationship to substance abuse, see A 

Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and 

Transgender Individuals (CSAT 2001b, pp. 

61–67).

• Fear of sex while abstinent. Many women 

enter treatment with little or no experience 

of sexual relationships without being under 

the infl uence of substances. For women with 

a history of sexual trauma, using alcohol 

and drugs to manage emotions while having 

sex may have served as an important coping 

mechanism. Subsequently, women may 

become fearful of having sex without the 

assistance of substances (Covington 2000, 

Note to Clinicians

Safety issues for the client or her children may preclude the partner’s involvement. If the client 

does not feel safe involving her partner, the emphasis should change to safety planning.
Clinical Activity: 

Exploring the History and Influence of Relationships: Sociogram 

Using a simple diagram (referred to as a sociogram) that was pioneered by J. L. Moreno in the 

1940s, clients can highlight their most influential female and/or male relationships (including 

positive and negative attributes). Starting with this diagram, counselors can use this activity 

as a foundation to help women explore how these relationships influence current relationship 

patterns, preference for male or female friends, attitudes toward other women and/or men, and 

the development of support systems. 

Depending on your goal, you can have the client focus only on the men or women who have 

been most influential in their lives. Generally, the exercise provides more clarity for the client if 

you focus on only one gender at a time. Yet, your selection depends on your treatment goal, the 

client’s current struggles, and previous relationship history. If the woman is having a diffi cult time 

connecting with other women in treatment, it may be helpful to start with a history of her female 

relationships. Even though there are other ingredients that influence how a woman relates to 

and views other women (namely gender socialization), a sociogram that begins with the history of 

female relationships may enhance awareness of the issues that impede her ability to relate to other 

women. At other times, it may be more fruitful to focus on the history of male relationships with 

women due to clinical issues that involve men. Here are directions and a sample of a sociogram on 

female relationships: 

Provide the client with a piece of paper and a pencil, and ask her to list the most infl uential 

females throughout her life. The list should include women who have had the most signifi cant 

impact—both positive and negative. It should not be limited to family members, but instead 

include women throughout her lifespan up to the present day. The list should consist of women 

who have had a powerful influence even if the encounter was brief. You could ask her to limit the 

list to six to eight women for this exercise. She can always go back and add individuals later on. 

After compiling this list (it takes about 3 to 5 minutes), have the client turn the page over and draw 

a circle (about the size of a quarter) in the middle of the page and have her place her own name 

within the circle. Referring back to her list of influential women, ask the client to draw a circle for 

each influential woman on the piece of paper and to place the circles in reference to how infl uential 

they have been in her life—placing the most influential women closer to her circle and other 

women with less influence farther away on the page. The circle can be placed anywhere on the 

paper. For example, if you have a client with a physically abusive mother and the client feels that 

this history prevented her from trusting other women, she may place the circle, labeled “Mother” 

quite close to her circle. 

After instructing the client to draw and place the circles on the page so that the placement 

represents how influential or how much she believes this relationship affected her, ask the client 

to go back and list three things in each circle that she learned about other women based on each 

specific relationship. For example, you may say to the client, “What did you learn about women 

based on your relationship with your mother and how your mother was with you? Select three 

things and write them in the circle that is labeled ‘Mother.’” 

Upon completion, have the client present her sociogram. This exercise works quite well in a 

women’s group and in individual counseling. In group, it promotes a dynamic discussion on how 

women learn to relate to each other, and it creates an opportunity to understand how each client’s 

history of female relationships can influence current relationships in treatment and recovery. As a 

counselor, you can promote further discussion by asking the following questions: 

148 Substance Abuse Treatment for Women 
Clinical Activity:
 

Exploring the History and Influence of Relationships: Sociogram
 

(continued)
 

Are there any themes or recurrent patterns in this sociogram? 

1. 	 How does this history influence your relationship with other women in treatment, in therapy 

groups, and in support groups? 

2. 	 Can you provide a specific and recent example of how your history of relationships affected or 

contributed to a specific situation in treatment? 

Sample Sociogram Exercise: “What have I learned from each 

relationship about other women?” 

High 

School 

friend: Lenore 

Kind, patient, 

undependable, 

will drop you 

for men 

Current 

Girlfriend: Cheryl 

Used drugs together, 

loyal, secretive, 

trustworthy 

Sponsor: 

Georgia 

Steadfast, 

dependable, 

patient 

Sister: 

Amy 

Competitive, will 

steal your men, 

angry Self 

Mother: 

Competitive, not 

dependable, cold 

Sister: Tara 

Unavailable, 

secretive, angry 

Substance Abuse Treatment for Women 149 
1997). Trauma survivors may view sex as 

taboo or hurtful and their sexual responses 

as bad. In addition, sexual relationships 

sometimes can trigger painful memories 

of past abuse that can create diffi culties 

for women, particularly in early recovery 

(Covington 1997; Finkelstein 1996). 

• 	 Sexual dysfunctions. Alcohol and drugs 

interfere with sexual sensitivity and 

enjoyment in many ways. They disrupt the 

delicate balance of a woman’s hormonal 

system, interfering with her body’s 

emotional, reproductive, and physiological 

functions (Greenfield and O’Leary 2002). 

Women with substance use disorders have the 

same kinds of sexual dysfunctions as those 

without the disorder (lack of orgasm, lack 

of lubrication, lack of sexual interest, etc.), 

but they have more problems more often 

(Covington 2000). 

• 	 Sexual and interpersonal violence. Sexuality 

often is associated with violence and 

abuse for female clients with histories of 

trauma. Consequently, they may be fearful, 

angry, and distrustful, and have diffi culty 

functioning sexually. Given the association 

between substance abuse and sexual abuse 

(Ullman et al. 2005), women who have been 

abused may use alcohol or drugs to numb 

the emotional pain of the abusive experience. 

This can create a spiraling relationship where 

many women use substances to alleviate the 

sexual difficulties they are experiencing. 

But the alcohol or drugs only exacerbate the 

problem. Women who are under the infl uence 

of drugs are at greater risk for sexual and 

physical aggression (Blume 1991; Testa et al. 

2003), and this remains true with pregnant 

women who have substance use disorders 

(Velez et al. 2006). 

• 	 Sexually transmitted diseases (STDs). 

The use of alcohol and drugs increases the 

likelihood of contracting STDs, including 

HIV/AIDS. There are three primary reasons 

for this increased risk. When drunk or high, 

many women neglect to protect themselves 

against STDs or to make sure they do not 

use contaminated needles (Evans et al. 2003; 

Pugatch et al. 2000). Often women with 

substance use disorders fi nd themselves 

in relationships with men who are also 

chemically dependent, thereby increasing 

the risk that their partner may have STDs 

or are HIV positive. In addition, rates of 

other infectious diseases among women 

with substance use disorders tend to be 

higher than among other female populations 

(CSAT 1993c; Grella et al. 1995). Notably, 

preliminary findings suggest that women who 

inject illicit drugs and have sex with other 

women exhibit increased HIV infection and 

risk behaviors in comparison to other people 

who use injection drugs (Young et al. 2005). 

In addition to research pertaining to prevalence, 

counselors need to address clinical issues 

associated with infectious diseases. Specifi cally, 

shame and stigma are highly associated with 

sexually transmitted diseases and HIV infection 

(Fortenberry et al. 2002), and, as a result, 

women who are addicted and infected with 

a sexually transmitted disease are likely to 

perceive and experience a more profound 

sense of shame and higher levels of stigma— 

potentially serving as a barrier to engaging in 

help-seeking behavior. 

Pregnancy 

Pregnancy creates stress for many women. 

Literature suggests that this stress can come 

from the woman’s physical discomfort; her 

anxiety about the health of her fetus and how 

she will care for her baby; or her shame from 

the social stigma of using drugs, alcohol, or 

tobacco while she is pregnant (Daley et al. 

1998). Providers can create an atmosphere that 

supports talking freely about pregnancy and 

recognize that ambivalence toward pregnancy 

is a normal reaction. Counselors should make 

a careful assessment of the woman’s existing 

parenting and other family responsibilities and 

of the social services and economic resources the 

mother needs. 

Some women experience feelings of ambivalence 

about their pregnancy that become apparent 

during treatment. Educational programs, 

particularly for young women, that review 

the effects of alcohol, drug, and tobacco use 

on pregnant women and their fetuses may 

150 Substance Abuse Treatment for Women 
provide motivation to enter treatment, but this 

information will probably also generate concern 

over the status of their fetus. Counselors should 

be supportive of the client as she processes this 

emotionally difficult information. Counselors 

must understand a woman’s guilt, shame, 

and unspoken feelings about the effects of 

substance use on fetal health and development. 

Counselors can advocate for fetal well-being but 

must also give the mother information that is 

nonjudgmental. It is important for counselors to 

stress that “it is never too late to stop,” and that 

whenever pregnant women reduce or stop drug 

and alcohol use, benefits are obtained! 

Women should be encouraged to consult with 

an obstetrician or geneticist regarding their 

concerns of prenatal exposure on the fetus. 

However, caution should be exercised in 

evaluating pregnancy outcomes based on use 

of alcohol, drugs, or tobacco during pregnancy 

and their possible effects on the newborn. It is 

almost impossible to make accurate predictions 

on neonatal outcomes. Nevertheless, a woman 

should have support from her substance abuse 

counselor to meet with her prenatal care 

provider to discuss these issues. 

After detoxification and stabilization, 

counselors should offer the important message 

that abstinence, staying in substance abuse 

treatment, and prenatal care can reduce the 

impact of substance use on the fetus (Bolnick 

and Rayburn 2003). Research indicates that 

a positive environment is as enriching to 

a child’s early growth and development as 

prenatal exposure to substances is detrimental 

(Frank et al. 2001; Hurt et al. 2001). After the 

child is born, a mother can work to create a 

positive environment for her child’s healthy 

development. This approach emphasizes the 

recovering woman’s control and self-effi cacy; 

it is another element of empowerment for 

recovering women (Covington 2002a). 

Parenting 

A woman’s relationship with her children and 

her identity as a mother play a vital role in her 

sense of self. These relationships are important 

in recovery from substance use disorders. The 

consensus panel believes that substance abuse 

treatment programs should offer treatment that 

addresses the critical component of parenting 

connections to children, as well as a full range 

of children’s physical and mental health care, 

along with other services, whether within a 

treatment program itself, or by referral to a 

collaborating agency. Refer to chapter 5 for 

more specific information on programming 

across each level of care for women who are 

pregnant and/or have children. 

Most mothers who are in substance abuse 

treatment feel a strong connection with their 

children and want to be good mothers. Most 

want to maintain or regain custody of their 

children and become “caring and competent 

parents” (Brudenell 2000, p. 86). Women who 

believe they have not cared for their children 

adequately or who believe that they are 

perceived as having neglected their children 

carry enormous guilt (Sun 2000). Therefore, for 

many women, maintaining caring relationships 

with their children is sufficient motivation to 

keep them in treatment. Unfortunately they 

often have inadequate role models in their own 

lives or lack the information, skills, or economic 

resources that could make motherhood less 

difficult (Camp and Finkelstein 1997; Moore and 

Finkelstein 2001). They also have the challenge 

of balancing the work necessary for recovery 

with their tasks as mothers. Another challenge 

treatment providers may face is the mother who 

is developmentally disabled to the extent that 

her mothering is inadequate. Ensuring the safety 

of her children while respecting the mother’s 

choice to care for them requires careful case 

management to provide support for the mother. 

People take from their family relationships a 

basic sense of their own identity and an equally 

basic model for the relationships they later 

develop with others. Mother–child relationships 

are understood to be the model for the child’s 

future relationships. At the same time, because 

women tend to develop their sense of self 

through relationships, a woman’s identity is 

also deepened when she becomes a mother. 

Society places a high value on a woman’s ability 

to mother, and her own perceived success or 

Substance Abuse Treatment for Women 151 
failure in this endeavor forms an important 

aspect of her self-concept. For a mother with 

a substance use disorder, this concept can be 

paramount (Feinberg 1995). 

Parenting programs 

Research findings are inconsistent in 

demonstrating the effectiveness of behavioral 

parenting programs for improving the parent– 

child relationship and children’s psychological 

adjustment among mothers who have substance 

use disorders (for review, see Suchman et al. 

2004; Suchman et al. 2007; Velez et al. 2004). 

More research is needed to evaluate the most 

effective parenting approaches and to address 

research methodological issues surrounding 

parenting program evaluations. In general, 

literature appears to support combining 

behavioral training with attachment-based 

parenting interventions (relational model). 

A strengths-based relational approach to 

parenting assumes maternal assets already 

exist that can be identified and built on, and 

that the emotional quality of the parent–child 

relationship is equally important in improving 

the parent–child relationship and psychological 

adjustment of the child. In essence, parenting is 

a relationship—not solely a set of skills. Some 

topics for parenting skills and relationship 

building include: 

• 	Age- and developmentally appropriate 

behavioral expectations for children. 

• 	Children’s emotional, physical, and 

developmental needs. 

• 	Parenting styles and other childrearing 

practices, including attachment-oriented 

approaches (defined as enhancing the 

parent’s ability to accurately perceive and 

sensitively respond to the emotional needs 

reflected in their child’s behavior) (Slade and 

Cohen 1996; Suchman et al. 2006). 

• 	 Strategies to improve nurturing that begin 

with helping mothers find a way to nurture 

themselves as an important step in learning 

how to nurture their children. 

• 	Constructive discipline strategies without 

corporal punishment. 

• 	Anger management strategies to assist parents 

in learning how they can appropriately 

manage their strong feelings. 

• 	Appropriate parent–child roles including 

modeling opportunities. 

• 	Integration of culturally congruent parenting 

practices and expectations. 

Clients need time to practice these new 

parenting skills and change patterns of behavior 

to improve interactions with their children 

(CSAT 2000b). It is helpful to match parenting, 

coaching, or other support groups to the 

woman’s ability to cope with her children and 

the other problems she is facing. Substance 

abuse counselors must simultaneously help 

mothers address their other ongoing challenges 

while teaching them to be better parents (Camp 

and Finkelstein 1997). Programs that provide 

support and parent training to mothers can 

also help children by building their self-esteem, 

supporting them educationally and emotionally, 

and assisting them to achieve developmental 

milestones. 

Children affected by maternal alcohol and 

drug dependence have increased vulnerability 

for physical, social-emotional, and academic 

problems (Conners et al. 2004; VanDeMark et 

al. 2005). Moreover, analysis from SAMHSA’s 

Women, Co-Occurring Disorders and Violence 

Study (WCDVS) suggests that children are also at 

an increased risk for physical child abuse when 

the mother has a current history of mental health 

symptoms, alcohol and drug use severity, and 

trauma (Rinehart et al. 2005). Thus, children 

need more than just adequate child care. 

The consensus panel recommends that an onsite 

child specialist or one available by referral 

should be a standard element of programs that 

include children. Assessment and screening 

for developmental and learning delays and 

social problems is necessary, as are play 

and expressive therapies that help children 

acknowledge and express feelings about their 

parents’ problems. Children should be provided 

with information regarding their mother’s 

substance use disorder in an age-appropriate 

152 Substance Abuse Treatment for Women 
manner. Counselors can help the mother and 

children frankly discuss issues surrounding 

substance use and recovery. A staff member 

providing therapeutic services for children 

should conduct substance abuse prevention 

activities for children of all ages. 

While a woman is learning to parent, her 

children need assistance to overcome the effects 

of her substance abuse. It is likely their mother 

has been emotionally and physically unavailable 

at times. Counselors can help children realize 

that their mother’s behavior was unintentional 

and, as she regains control of her life, she will 

likely become more available. In addition, 

Alateen; psychoeducational curricula, such 

as the National Association for Children of 

Alcoholics “Celebrating FamiliesTM;” and onsite 

individual and group therapy can provide 

further support to children. 

Parenting issues for women with 

trauma histories 

A history of trauma can affect both how a 

woman experiences parenting and how effective 

she is as a parent. Factors that affect a woman’s 

parenting include the extent of trauma history, 

who the abuser was, and a woman’s parenting 

role models, as well as whether she has been 

involved with trauma work or has developed the 

skills to manage trauma memories and feelings 

(Melnick and Bassuk 2000). Several major 

parenting issues for trauma survivors can be 

identifi ed: 

• 	 Many women feel shame, guilt, and selfblame, which can interfere with their 

emotional availability to their children. 

This includes a mother’s self-criticism 

or depression when evaluating current 

parenting as well as her belief that she 

deserves blame for inadequate parenting, 

or feeling that her children’s behavior is 

an attack because they had inadequate 

parenting. 

• 	Interaction with a child can trigger a 

mother’s traumatic past. This includes 

experiencing a child’s misbehavior as a 

traumatic trigger, children’s distress or need 

for bonding reminding a mother of her own 

vulnerabilities, and having posttraumatic 

stress disorder (PTSD) symptoms triggered 

by normal developmental events such as 

breastfeeding, bathing a child, and providing 

sexual education to a child. Likewise, a 

mother may experience heightened anxiety 

and vigilance when one of her children 

reaches the same age that her own prior 

sexual abuse or trauma began or occurred. 

For example, if a client witnessed her 

younger brother getting shot when she was 

12, she may encounter more traumatic stress 

symptoms as her oldest child reaches the 

same age as her brother. 

• 	A mother may internalize and reenact 

the role of both victim and perpetrator in 

response to trauma. This may cause her to 

worry that her children will be mistreated 

and lead to either overprotectiveness or 

helplessness, a reluctance to set limits out of 

fear of identifying with a perpetrator. 

• 	 Female clients will need to come to terms 

with having been inadequately nurturing 

parents at times and with the complexities 

of providing a better relationship with their 

children (Melnick and Bassuk 2000). 

Trauma-informed parent training assists 

mothers in identifying their triggers, learning 

appropriate boundaries and discipline, and 

learning nurturing behaviors so they can care 

for their children in healthy ways. As the 

mother becomes more stable, she will need to be 

prepared for the possibility that her children 

will feel safer in acting out their previous 

distress. Programs can prepare women in 

early recovery for this predictable event with 

information, coaching for effective parenting, 

and reframing the children’s behavior as a signal 

that they feel safer and can afford to express 

themselves. 

Children who are not in a 

mother’s care 

Regaining custody or re-establishing their role 

of primary caregiver can be a major motivating 

factor for women in treatment. Professionals at 

all levels of care are encouraged to support the 

relationship between mothers and children and 

to support and facilitate ongoing connections 

with their children in foster care or with 

Substance Abuse Treatment for Women 153 
relative caregivers. Since parent–child visiting 

is an essential ingredient toward reunifi cation, 

substance abuse treatment providers may be 

able to provide supervised visits, offering an 

opportunity for therapeutic intervention and 

the mother’s attention to her relationship with 

children not in her custody. Yet, numerous 

factors inhibit visitation, including the mother’s 

health status, transportation needs, and 

support from others (Kovalesky 2001), and staff 

should be aware of these variables. Ultimately, 

counselors will need to help women recognize 

how their recovery needs can complicate meeting 

their children’s needs and determine the pacing 

of reunifi cation efforts. 

Occasionally, a mother in substance abuse 

treatment expresses a desire not to keep her 

children. The woman may feel unable to be a 

mother or has no support in doing so, or her 

children have been cared for by others for a 

long time. In other cases, it is possible that these 

children were the result of rape or prostitution. 

Sometimes it is in the best interest of both the 

mother and the child(ren) for the mother to 

relinquish care. Counselors must be careful to 

allow the decision to belong to the woman, to 

listen to her ambivalence, and to support her 

regardless of her decision (CSAT 2001b). 

Children with special needs 

Some mothers with substance use disorders 

have children with special needs, possibly as a 

result of alcohol or drug use during pregnancy, 

inadequate prenatal care, poor nutrition during 

pregnancy, or other factors. In addition to 

coping with the personal guilt, mothers will 

find that these children demand extra care 

and attention and create additional stresses 

during recovery. Careful assessment of these 

children by trained professionals is essential. An 

educational and/or treatment plan should result 

from an assessment that is integrated with the 

mother’s treatment plan. Because so many of 

the children who are included in treatment with 

their mothers have emotional or developmental 

problems, there is a real need for child 

specialists on staff (Conners et al. 2004; CSAT 

2000b). A linkage to programs for children 

with special needs and children with disabilities 

would be an asset in providing the services these 

children need. 

History of Trauma 

Trauma can result from numerous experiences, 

including emotional, physical, and sexual 

abuse, as well as assault, war, natural disasters, 

terrorism, and interpersonal violence that 

occurs between family members or with intimate 

partners. Women who experience or witness 

violence, particularly actions that threaten 

their lives and safety, can become traumatized 

by these events (Herman 1997). The Diagnostic 

and Statistical Manual of Mental Disorders, 

4th Edition, Text Revision (DSM-IV-TR) defi nes 

trauma as “involving direct personal experience 

of an event that involves actual or threatened 

death or serious injury, or other threat to 

one’s physical integrity; or witnessing an event 

that involves death, injury, or a threat to the 

physical integrity of another person; or learning 

about unexpected or violent death, serious 

harm, or threat of death or injury experienced 

by a family member or other close associate” 

(American Psychiatric Association [APA] 2000a, 

p. 463). 

Women respond to and are affected by trauma 

in a variety of ways. Based on their histories, 

circumstances, and other factors, some women 

experience traumatic stress symptoms that 

dissipate over time, while other women are 

resilient to the effects of trauma and recover 

from it quickly (Foa and Rothbaum 1998). 

Some women develop psychological disorders 

including PTSD and other anxiety and mood 

disorders, and other women may use alcohol, 

tobacco, and drugs to cope with the trauma and 

its symptoms. Still others may replicate their 

trauma by engaging in problematic parent–child 

interactions, including abuse and neglect 

(McMahon and Luthar 1998). A family history of 

anxiety, early traumatic violence, and repeated 

exposure to trauma can predispose an individual 

to develop severe problems. The Adverse 

Childhood Experiences Study (Felitti et al. 1998) 

reflected a strong association between health 

risk behavior and disease for both adult men 

154 Substance Abuse Treatment for Women 
and women to exposure to emotional, physical, 

or sexual abuse, and household dysfunction 

during childhood. 

The relationship between trauma 

and substance abuse 

Substance abuse and victimization appear to be 

highly correlated; drug abuse increases the risk 

of violent assault, and victimization appears to 

increase the risk of substance abuse (El-Bassel 

et al. 2005; Kendler et al. 2000; Kilpatrick et 

al. 1997). Nevertheless, the connection between 

substance use and abuse and interpersonal 

violence often is complex, especially for women. 

Men who abuse substances are at high risk 

of committing violence against women and 

children. Women who use substances are more 

at risk for being abused because of relationships 

with others who abuse substances, impaired 

judgment while using alcohol or drugs, and 

being in risky and violence-prone situations 

(Testa et al. 2003). Survivors of abuse may 

become dependent on alcohol and drugs to 

manage trauma symptoms and reduce tension 

and stress from living in violent situations. 

Thus begins a cycle of “victimization, chemical 

use, retardation of emotional development, 

limited stress resolution, more chemical 

use, and heightened vulnerability to further 

victimization” (Dayton 2000; Steele 2000, p. 72). 

A history of trauma is common in the lives of 

women with substance use disorders. Female 

survivors of sexual trauma were found, in one 

study, to be dependent on more substances, to 

have had more hospital stays and emergency 

department visits, and to be less able to care for 

their children than women who had not been 

sexually abused (Young and Boyd 2000). Girls 

who suffer physical and sexual abuse by dating 

partners are more likely to engage in risky 

behaviors such as smoking, binge drinking, 

and cocaine use (Silverman et al. 2001). In 

another study, adverse childhood circumstances 

predicted binge drinking among adult women 

(Timko 2008). 

Alcohol and drug use by trauma survivors can 

be adaptive at first. Some victims use substances 

to numb psychological effects of the trauma. 

Some substances help survivors dissociate the 

trauma from their consciousness (Herman 

1997). Women who have histories of violence and 

trauma have a higher propensity for substance 

use disorders and are more likely to encounter a 

difficult recovery from substance use disorders. 

Their treatment is typically complicated because 

of the interrelationship between trauma and 

substance use, the role that substances play 

in managing traumatic stress symptoms, and 

sequelae from the experience of trauma such as 

depression and other psychological disorders. 

To obtain more specific information on the 

impact of trauma, traumatic stress disorders, 

symptoms of PTSD and associated symptoms, 

and treatment approaches, refer to TIP 42 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005e) and the 

planned TIP Substance Abuse and Trauma 

(CSAT in development h). 

Interpersonal violence 

Violence dramatically affects the physical and 

emotional health of victims and witnesses. 

The United Nations defines violence against 

women as “any act of gender-based violence 

that results in, or is likely to result in, physical, 

sexual or psychological harm or suffering to 

women, including threats of such acts, coercion 

or arbitrary deprivation of liberty, whether 

occurring in public or in private life” (United 

Nations General Assembly 1993, p. 2). The 

National Violence Against Women Survey 

(Tjaden and Thoennes 1998; 2000; 2006), 

conducted in 1996, estimated that in the year 

before the survey, almost 2 million women were 

physically assaulted and more than 300,000 

women experienced a completed or attempted 

rape. Estimates of lifetime incidence increased 

to more than 50 million women who were 

physically assaulted and almost 20 million who 

experienced rape or attempted rape. Moreover, 

sociologists have commented that this level of 

violence has created a culture of fear for many 

women, observing that women feel they need 

to be alert and aware of their surroundings to 

protect themselves against assault and rape 

(Gordon and Riger 1989). 

Substance Abuse Treatment for Women 155 
Women are more likely to become victims of 

intimate partner abuse (Catalano 2007), and 

men and women become victims of interpersonal 

violence under different circumstances. Women 

often experience violence in the privacy of their 

home (Catalano 2007; Covington 2002a; Tjaden 

and Thoennes 2006). Both boys and girls are at 

risk for physical and sexual abuse by parents 

and people they know, but this risk changes over 

the course of life. As girls move into adolescence 

and adulthood, they continue to be at risk for 

interpersonal violence. Often their abuser is 

someone with whom they have a relationship. 

For example, about one in five high school 

girls reportedly has suffered sexual or physical 

abuse from a boyfriend (Ackard and NeumarkSztainer 2003; Silverman et al. 2001, 2004). 

For an overview of violence and women, see 

Figure 7-1. 

Violence and abuse also occur in lesbian 

relationships. While research is limited, studies 

reviewed by Renzetti (1993) have indicated that 

lesbians experience partner violence at about 

the same rate as heterosexual women. As is the 

case with violence in heterosexual relationships, 

alcohol consumption often is part of the 

battering (Schilit et al. 1990). In comparing 

the prevalence of domestic violence between 

homosexual males and females, the National 

Coalition of Anti-Violence Programs (2007) 

reports there are no overall differences. 

Childhood sexual and physical 

abuse 

A history of childhood sexual or physical abuse 

(or both) is a significant risk factor for the 

development of a substance use disorder (Evans 

and Sullivan 1995). Two models help explain 

this—the distress coping model and the emotion 

regulation model. It is likely that substances 

not only serve as means of coping with negative 

emotions generated by childhood abuse, but 

Figure 7-1 

Violence and Women 

• 	 The strongest risk factor for being a victim of intimate partner violence is being female. 

• 	 One of every six women has been forcibly raped at some time in her life, and women are as 

likely to be raped as adults as they are as minors. 

• 	 While women are at a significantly greater risk in comparison to men of being raped by all 

types of offenders, 43 percent of all female victims were raped by either a current or former 

intimate partner. 

• 	 Between 25 and 50 percent of women will be abused by male partners during their lifetime. 

• 	 Women are injured as a result of domestic violence about 13 times more frequently than men. 

• 	 Women with fewer resources or greater perceived vulnerability—girls and those experiencing 

physical or psychiatric disabilities or living below the poverty line—are at even greater risk 

for domestic violence and lifetime abuse. 

• 	 Interpersonal violence is characterized by a pattern of physical, sexual, or psychological 

abuse. The most common pattern in domestic violence is escalation in frequency and severity 

over time. 

• 	 When women are violent toward family members, it often is in self-defense. 

• 	 A history of intrafamilial violence may be the most influential risk factor for a woman’s abuse 

of substances. 

• 	 Violence in the media significantly affects attitudes and behaviors related to violence. It 

increases fear and mistrust, desensitizes people to violence, and glamorizes risk-taking 

behaviors and violence. 

Source: American Psychological Association 1996; Brownridge 2006; Tjaden and Thoennes 2006 

156 Substance Abuse Treatment for Women 
in regulating emotions by enhancing positive 

feelings (Grayson and Nolen-Hoeksema 2005; 

Simpson 2003; Ullman et al. 2005). 

A study of 1,411 women born between 1934 and 

1974 found that women who experienced any 

type of sexual abuse in childhood were more 

likely than those who were not abused to report 

drug or alcohol dependence as adults. In fact, 

childhood sexual abuse was associated more 

strongly with drug or alcohol dependence than 

with any other psychiatric disorder. This study 

is based on data from women in the general 

population, as opposed to clinical studies of 

women in treatment (Kendler et al. 2000). 

Clinical studies have documented that up to 75 

percent of women in substance abuse treatment 

have a history of physical and/or sexual abuse 

(Ouimette et al. 2000; Teusch 1997). Earlier 

studies have shown that women who abuse 

substances are estimated to have a 30- to 

59-percent rate of current PTSD (Najavits et 

al. 1998), which is higher than the rate in men 

who abuse substances (CSAT 2005a). A history 

of sexual and/or physical abuse puts women at 

risk for psychiatric hospitalization (Carmen 

1995), depression (Herman 1997; Ross-Durow 

and Boyd 2000), eating disorders (Curtis et 

al. 2005; Janes 1994; Miller 1994; Smolak and 

Murnen 2001), and self-inflicted injury (Dallam 

1997; Haswell and Graham 1996; Miller and 

Guidry 2001). See also TIP 36 Substance Abuse 

Treatment for Persons With Child Abuse and 

Neglect Issues (CSAT 2000b). 

Co-Occurring Disorders 

When working with women with co-occurring 

mental and substance use disorders, substance 

abuse treatment counselors need to apply 

the tools of the mental health professional, 

especially in knowing when and where to 

refer clients with co-occurring disorders. 

Substance abuse treatment providers do not 

necessarily have to be trained as mental health 

professionals, but making appropriate referrals 

and coordinating the services needed by these 

clients requires a solid grasp of the differences 

in treatments, role of medications, and available 

resources. The following section provides an 

overview of co-occurring issues and highlights 

three disorders that are prevalent in substance 

abuse treatment among women. For more indepth coverage of treatment for those with cooccurring substance use and mental disorders, 

review TIP 42 Substance Abuse Treatment for 

Persons With Co-Occurring Disorders (CSAT 

2005e). 

An overview of issues 

Both the substance abuse and mental health 

care fields understand that clients can 

enter treatment with issues they perceive 

as interwoven, whether or not the services 

themselves are. To address the dilemmas facing 

the people they serve, mental health, substance 

abuse, and trauma services are opening a 

dialog with one another, paving the way toward 

providing an appropriate, integrated system of 

care for each client in every system. 

An integrated care framework provides 

assessment and treatment wherever the 

woman enters the treatment system, ensures 

necessary consultation for her issues when 

a given individual or program does not have 

the necessary expertise, and encourages all 

counselors and programs to develop competence 

in addressing co-occurring disorders. When 

women are assessed at a facility that does not 

have all the services they need, staff members 

at that facility are responsible for ensuring that 

the women are assessed at other appropriate 

facilities. Too often, services may over- or 

under-treat one of the disorders (Miller 1994a). 

Staff members also are responsible for following 

up with the cooperating facility to ensure that 

clients receive proper care. 

The need for ongoing evaluation of co-occurring 

disorders is critical because both substance 

abuse and substance withdrawal can mimic 

or mask co-occurring psychiatric disorders. 

The client’s internal turmoil can result in 

overwhelming affect and chaotic behavior that 

creates heavy demands for providers. Women 

with co-occurring substance use and mental 

disorders are likely to have PTSD, other anxiety 

disorders, depression, or eating disorders 

(particularly bulimia). While women are also 

more willing to identify social and psychiatric 

problems, they appear to have more diffi culty 

Substance Abuse Treatment for Women 157 
in acknowledging problems with substance use 

(Mangrum et al. 2006). Treatment services 

that provide an integrated system of care 

can naturally assist women in exploring the 

interaction and impact of substances and mental 

health without supporting or reinforcing the 

polarization of each disorder that can arise 

when one disorder is easier to acknowledge by 

the client. 

Co-occurring mental and substance use 

disorders often result in poor psychosocial 

functioning, health problems, medication 

noncompliance, relapse, hospitalizations, 

homelessness, and suicidal behavior (Reed 

and Mowbray 1999). Co-occurring disorders 

are associated with poorer treatment outcomes 

for women with substance use disorders and 

contribute to high rates of treatment dropout 

(Bernstein 2000). Among women in the child 

welfare system, the prevalence of co-occurring 

disorders is high and the need for services is 

paramount. More often than not, mothers’ cooccurring disorders interfere with the likelihood 

of family reunification—especially if there are 

numerous needs, such as vocational, housing, 

and mental health services (Choi and Ryan 

2007). Thus, appropriate referrals and case 

management are needed to retain these clients in 

substance abuse treatment and to afford the best 

possible outcome for women and their children. 

Pregnant women and co-occurring 

mental illness 

Pregnancy can aggravate the symptoms of cooccurring mental illness. This can be a result of 

the hormonal changes and stresses that occur 

during pregnancy, some medications given 

during pregnancy or delivery, the stresses of 

labor and delivery, the challenges and hormonal 

changes with lactation, and adjusting to and 

bonding with a newborn (Grella 1997). Women 

with co-occurring disorders sometimes avoid 

early prenatal care, have diffi culty complying 

with healthcare providers’ instructions, and are 

unable to plan for their babies or care for them 

when they arrive. According to the literature, 

women with anxiety disorders or personality 

disorders have a greater risk of postpartum 

depression (Grella 1997), and mood disorders 

affect treatment outcome among pregnant 

women who are drug dependent (Fitzsimons 

et al. 2007). More outcome research is needed 

to evaluate the role of co-occurring disorders 

among pregnant women and the impact of 

treatment for co-occurring disorders on prenatal 

and postnatal care. 

It is important to remember that women can 

become depressed not only after childbirth but 

during pregnancy. According to the National 

Women’s Health Information Center (HHS 

Advice to Clinicians: 

Women With Co-Occurring Disorders 

• Provide women who have co-occurring disorders with comprehensive coordinated

services using an integrated treatment model. 

• Screen and assess for trauma as a standard practice for women in treatment for

substance use disorders. 

• View services as long term, suggesting a range of continuing care services and peer 

support, such as 12-Step programs, group therapy, or women’s support groups. 

• Maintain regular contact with clients and advocate for them; adapt case management

models that promote regular contact with clients. 

• Attend to a client’s reaction to medication and compliance, particularly when a 

woman is treated for psychiatric illnesses. Learn about medications effective for 

anxiety, depression, and other mental disorders; their safety profile, side effects, and 

possibilities for cross-addiction; and length of time needed for symptoms to decrease. 

• Offer encouragement to women with co-occurring disorders and reward them for 

gains made in treatment to help them establish a stronger sense of self-worth. 

Source: DiNitto and Crisp 2002. 

158 Substance Abuse Treatment for Women 
Postpartum Depression: An Under-Diagnosed Disorder 

According to the DSM-IV-TR (APA 2000a), postpartum depression begins within 4 weeks after 

delivery. Episodes occurring after this period are considered “ordinary” depression. Risk 

factors for postpartum depression include a history of depression, psychological distress or 

psychiatric diagnosis before or during pregnancy, or a family history of psychiatric disorders 

(Nielsen Forman et al. 2000; Steiner 2002; Webster et al. 2000). Prospects for recovery from 

postpartum depression are good with supportive psychological counseling accompanied as 

needed by pharmacological therapy (Chabrol et al. 2002; Cohen et al. 2001; O’Hara et al. 

2000). Antidepressants, anxiolytic medications, and even electroconvulsive therapy have all 

been successful in treating postpartum depression (Griffiths et al. 1989; Oates 1989; Varan et 

al. 1985). (Note that some medications pass into breast milk and can cause infant sedation.) 

Patients with postpartum depression need to be monitored for thoughts of suicide, infanticide, 

and progression of psychosis in addition to their response to treatment. 

The term “postpartum depression” encompasses at least three different entities: 

• 	Postpartum or maternity “blues,” which affects up to 85 percent of new mothers 

• 	Postpartum depression, which affects between 10 and 15 percent of new mothers 

• 	Postpartum psychosis, which develops following about one per 500–1,000 births, according 

to some studies (Steiner 1998) 

Postpartum blues is temporary depression occurring most commonly within 3–10 days after 

delivery and may be caused by progesterone withdrawal (Harris et al. 1994), a woman’s 

emotional letdown that follows the excitement and fears of pregnancy and delivery, the 

discomforts of the period immediately after giving birth, fatigue from loss of sleep during 

labor and while hospitalized, energy expenditure at labor, anxieties about her ability to care 

for her child at home, and fears that she may be unattractive to her partner. Anticipation and 

preventive reassurance throughout pregnancy can prevent postpartum blues from becoming 

a problem. Women with sleep deprivation should be assisted in getting proper rest. Symptoms 

include weepiness, insomnia, depression, anxiety, poor concentration, moodiness, and 

irritability. These symptoms tend to be mild and fleeting, and women usually recover completely 

with rest and reassurance. Followup care should ensure that the woman is making suffi cient 

progress and not heading toward a relapse to substance abuse. 

Postpartum depression is a more severe case of the postpartum blues that does not go away 

after a few days. Beyond the temporary weepiness, irritability, and emotional letdown 

that follows delivery, postpartum depression involves a longer-term experience of despair, 

discouragement, guilt, self-reproach, and withdrawal from social contact. In many ways, 

postpartum depression resembles the grief and mourning that follows bereavement. Women 

may also lose their appetite and thus also lose weight, experience insomnia and severe mood 

swings, and have trouble coping with simple daily tasks, including the care of their newborns. 

Postpartum psychosis is a severe mental disorder. Women with this disorder lose touch with 

reality and may have delusions, hallucinations, and/or disorganized speech or behavior. Women 

most likely to be diagnosed with postpartum psychosis are those with previous diagnoses 

of bipolar disorder, schizophrenia, or schizoaffective disorder, or women who had a major 

depression in the year preceding birth (Kumar et al. 2003). Other studies reviewed by Marks 

and colleagues (1991) indicate that other risk factors for postpartum psychosis include previous 

depressive illness or postpartum psychosis, first pregnancy, and family history of mental illness. 

Recurrence of postpartum psychosis in the next pregnancy occurs in 30–50 percent of women 

(APA 2000a). Peak onset is 10–14 days after delivery but can occur any time within 6 months. 

In most cases, the severity of the symptoms mandates pharmacological treatment and sometimes 

hospitalization. The risk of self-harm and/or infanticide is widely reported and monitoring of 

mother–infant by trained personnel can limit these occurrences. 

Substance Abuse Treatment for Women 159 
2009), several factors increase a woman’s chance 

of depression prior to delivery: minimal support 

from family and friends, a history of depression 

or substance abuse, a family history of mental 

illness; anxiety about the condition of the fetus, 

problems with previous pregnancies or birth(s), 

relational or financial problems, and age of 

mother (younger women). 

Many pregnant women with co-occurring 

disorders are distrustful of substance abuse 

and mental health treatment providers, yet 

they are in need of multiple services (Grella 

1997). One concern is whether the mother can 

care adequately for her newborn. For her to 

do so requires family-centered, coordinated 

efforts from such caregivers as social workers, 

child welfare professionals, and the foster care 

system. It is particularly important to make 

careful treatment plans for women with mental 

health problems that include planning for 

childbirth and infant care. Women are often 

concerned about the effect of their medications 

on their fetuses. The consensus panel believes 

that treatment programs should work to 

maintain a client’s medical and psychological 

stability during her pregnancy and collaborate 

with other healthcare providers to ensure that 

treatment is coordinated. Providers also need to 

allow for evaluation over time for women with 

co-occurring disorders. Re-assessments should 

occur as they progress through treatment. 

Anxiety Disorders 

Anxiety disorders encompass physiological 

sensations of nervousness and tension, 

psychological worry characterized often by 

apprehension and rumination, and behavioral 

patterns of avoidance linked to the perceived 

source of anxiety. Some anxiety disorders have 

stronger familial ties than others. Anxiety 

disorders can develop without an identifi ed 

stressor or event or by exposure to acute or 

prolonged stress, (such as a traumatic event or 

a chronic condition such as living with poverty, 

in a dysfunctional family system, or as a result 

of migration and acculturation). PTSD, panic 

disorders, agoraphobia without panic, simple 

phobia, and generalized anxiety disorder are 

more common among women than among men 

(APA 2000a; Kessler et al. 1994; NIMH 2007). 

Among individuals with substance use disorders, 

traumatic stress reactions and PTSD are quite 

prevalent among women. As a result, this section 

will primarily focus on PTSD starting with 

a brief overview of treatment considerations 

for women with anxiety disorders. For more 

detailed information regarding anxiety disorders 

and trauma, refer to TIP 42 Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders (CSAT 2005e) and the planned 

TIP Substance Abuse and Trauma (CSAT in 

development h). 

General treatment considerations 

for anxiety disorders 

Women with anxiety disorders often seek 

medical help for physical (somatic) complaints 

such as fatigue, trembling, palpitations, 

sweating, irritability, sleeping problems, eating 

problems, irritable bowel syndrome, chronic 

pain, or dizziness. The symptoms of substance 

use and anxiety disorders are easily confused; 

therefore, abstinence must be established 

before a woman in substance abuse treatment is 

diagnosed with anxiety disorder. However, this 

does not preclude providers from working with 

Note to Clinicians 

It is important to remember that women can become depressed not only after childbirth but 

during pregnancy. According to the National Women’s Health Information Center (HHS 2009), 

several factors increase a woman’s chance of depression prior to delivery: minimal support 

from family and friends, a history of depression or substance abuse, a family history of mental 

illness; anxiety about the condition of the fetus, problems with previous pregnancies or birth(s), 

relational or financial problems, and age of mother (younger women). 

160 Substance Abuse Treatment for Women 
women to develop coping skills and strategies to 

manage the symptoms of anxiety. 

Cognitive–behavioral therapies (CBT) are 

effective treatments for anxiety disorders 

(Hofmann and Smits 2008) including, but 

not limited to, stress inoculation and other 

anxiety management strategies, desensitization 

processes, and imaginal and in-vivo (live 

reenactments) exposure therapies. Nonetheless, 

other types of therapy that address the 

underlying stress-producing events may be 

required (Frank et al. 1998). Clinical experience 

indicates that women with anxiety disorders 

and substance use problems may benefi t 

from alternative therapies as an adjunct to 

CBT, including acupuncture, exercise, and 

mindfulness meditation. One study indicated 

that socially phobic female outpatients 

being treated for alcohol dependence had 

better outcomes with CBT than with 12-Step 

facilitation therapy (Thevos et al. 2000). 

Benzodiazepines, which are commonly 

prescribed for anxiety disorders, can also be 

addictive and thus present a major problem for 

women with a substance use disorder. Providers 

may prescribe sedating antidepressants or 

selective serotonin reuptake inhibitors (SSRIs; 

Zweben 1996) instead. Newer nonaddicting 

medications, both SSRIs and non-SSRIs, are 

being prescribed as anti-anxiety agents (NIMH 

2007). Other options include anticonvulsants, 

antihypertensive agents, and newer neuroleptic 

medications. 

PTSD 

Although some type of trauma has been 

experienced by many women who use 

substances, not all women who have been 

traumatized will develop PTSD. An anxiety 

disorder, PTSD may involve other anxiety 

symptoms including panic attacks and avoidance 

(Brady et al. 2000). Refer to Appendix E for 

DSM-IV-TR criteria for PTSD. For those 

women who have PTSD, their symptoms will 

involve persistent re-experiencing of traumarelated events, avoidance of trauma-related 

material, and arousal (APA 2000a; Refer to 

Figure 7-2, p. 162, for PTSD symptom clusters). 

In addition, they will present other associated 

symptoms, such as depression and sleep 

disturbance. Subsequent to a heightened state 

of arousal, many women report signifi cant sleep 

difficulties characterized by nightmares, trouble 

falling sleep, frequent awakenings or problems 

in staying asleep, and apprehension in going to 

sleep. Among women with a history of sexual 

assault and PTSD, sleep difficulties have been 

noted as a significant motive to drink (Nishith et 

al. 2001). 

Along with the physiological and psychological 

symptoms that so often characterize PTSD, 

the experience of trauma can impact core 

assumptions and beliefs about self, others, 

and life (for review, see Janoff-Bulman 1992). 

One study (Hall 2000) demonstrated that the 

severity of the effects of trauma is evident 

in two core beliefs identified by survivors of 

childhood abuse who are in recovery: “I am 

nothing” (feeling inconsequential) and “I am 

bad or wrong.” In addition to the abuse or 

trauma itself, experiences that lead to feeling 

inconsequential include being unprotected from 

danger, telling someone about the abuse but 

not being believed, being told lies to conceal the 

abuse, and being unprepared for life transitions. 

This can lead to shutting down emotions and 

social isolation (Boyd and Mackey 2000a; Hall 

2000). The perpetrator may have put the blame 

on them (“you asked for it”). 

Treatment of PTSD 

Unlike other memories, memories of traumatic 

events may seem to have vague cognitive content. 

Rather, they often are sensory fragments such as 

Note to Clinicians 

Anxiety in a client can increase a counselor’s anxiety. A tip for staff working with women who 

abuse substances with anxiety disorders is to “slow down,” that is, start with general and nonprovocative topics and proceed gradually as clients become more comfortable talking about 

issues. 

Substance Abuse Treatment for Women 161 
Figure 7-2 

PTSD Symptoms 

Symptoms Client Experience Clinical Suggestions 

Reexperiencing • Feelings of being tossed from • Grounding techniques

• Flashbacks present and thrown into the • Develop support system

• Intrusive memories nightmare of the past • Education about trauma

• Nightmares • Feeling of being out-of-control and the symptoms of 

• Feeling of incompetence PTSD 

in managing symptoms or • Create sense of safety

triggers • Sleep hygiene strategies

• Imaginal rehearsal of

dreams 

• Cognitive and coping skills

to help separate past 

experiences from present 

moment 

Hyperarousal • All-or-none thinking • Normalize the symptoms

• Heightened startle • Fatigue • Ability to reassure

response • Feeling overwhelmed and • Containment strategies

• Irritability or heightened terror of being overwhelmed • Increasing coping and

aggression by feelings self-soothing capacities 

• Hypervigilance of • Difficulty in managing anxiety • Anxiety management

environment and engaging in self-soothing training 

• Sleep disturbance skills • Cognitive restructuring

Numbing and Avoidance • Disconnection from others’ • Affect regulation skills

• Staying away from and own feelings • Cognitive–behavioral

persons, places, and • Mechanical experience of life; strategies to build coping 

things that remind client possible discussion of painful skills 

of trauma events with limited affect • Education regarding

• Dissociation (not knowing substance use disorders 

or remembering events or and opportunities 

periods or experiencing to draw connections 

oneself as separate from what between substance use 

one was experiencing) and distress 

• Repeated use of substances or • When appropriate and

engagement in behaviors to with adequate training, 

avoid distress use exposure strategies 

• Isolation; profound loneliness including desensitization, 

• Ineffective defense against eye movement 

overwhelming feelings desensitization and 

reprocessing, prolonged 

exposure therapies 

Sources: APA 2000a; Cramer 2000; Melnick and Bassuk 2000; and Najavits 2002b. 

162 Substance Abuse Treatment for Women 
Figure 7-3 

Helpful Skills for Trauma Victims 

• 	 Self-knowledge, including attention to bodily cues 

• 	 Self-regulation, including recognizing triggers and expressing emotions appropriately 

• 	 Self-soothing; for example, using relaxation or guided imagery and keeping a journal 

• 	 Self-esteem and recognizing which behaviors to change 

• 	 Self-trust, including learning when to trust one’s own judgment and how to make decisions 

• 	 Limit setting and assertiveness, including recognizing personal limits and defending them 

• 	 Clear expression of needs and desires; for example, identifying a need, evaluating the need, 

and planning how to fi ll it 

• 	 Realization that the healthiest relationships have mutuality and reciprocity and learning to 

create them 

Source: Adapted from Harris and Fallot 2001a. 

sights, sounds, smells, or kinesthetic sensations 

and emotional states (van der Kolk 1996). 

Developing the ability to organize the traumatic 

events into coherent thoughts and narrative that 

can be expressed in some way can signifi cantly 

lessen somatic symptoms (see Figure 7-3; van 

der Kolk 1996). Some treatment methods 

support the premise that the trauma must be 

made conscious, effectively experienced, and 

integrated into present life (Volkman 1993). 

Some treatments suggest that coping strategies 

are the effective path in addressing PTSD, 

while other approaches heavily rely on the 

premise that repeated and prolonged exposure 

to anxiety-evoking material will gradually 

reduce PTSD symptoms through the process 

of extinction/habituation (Foa et al. 2007). A 

review of psychological treatments for PTSD is 

beyond the scope of this TIP. For a review of 

treatments, refer to the article, Psychosocial 

treatment of posttraumatic stress disorder: A 

practice-friendly review of outcome research 

(Solomon and Johnson 2002), along with the 

TIPs highlighted in the introduction to the 

Anxiety Disorders section earlier in this chapter. 

Women with substance use 

disorders and PTSD 

Substance abuse and the effects of trauma 

interact in complex ways in an individual. A 

treatment provider cannot assume that one is 

a primary problem and the other secondary. 

Nor is it always beneficial to delay working 

on trauma symptoms until the client has been 

abstinent for a predetermined minimum amount 

of time. The counselor should focus on the 

client’s current crisis and stabilizing her affect. 

Substance abuse can prevent full recovery 

from PTSD, and continuing PTSD symptoms 

may perpetuate use of substances and the 

development of substance use disorders. Two 

studies report double the lifetime prevalence 

of PTSD in women than in men: 11.3 percent 

versus 6 percent and 10.4 percent versus 5 

percent (Breslau et al. 1991; Kessler et al. 1995, 

respectively). These studies found that women 

were twice as likely as men to develop PTSD 

after exposure to a trauma, suggesting that 

women are particularly vulnerable to PTSD or 

that the particular type of trauma experienced 

by women is more likely to result in PTSD. In 

a study that sampled 558 cocaine-dependent 

outpatient clients on current rates and symptoms 

of PTSD, women were three times more likely to 

meet diagnostic criteria for PTSD (Najavits et al. 

2003). 

Najavits and colleagues (1997) cite studies 

demonstrating that women with substance use 

disorders have higher rates of PTSD (30 to 60 

percent) in comparison to men, most often as the 

result of physical or sexual assault. Women with 

substance use disorders have also been found to 

Substance Abuse Treatment for Women 163 
have higher rates of repeated trauma by family 

perpetrators than men who abuse substances 

(Grice et al. 1995). Rape has been found to be the 

most likely form of violence to lead to PTSD for 

both women and men, and female rape victims 

may be particularly vulnerable to developing 

substance use disorders because of the traumatic 

nature of rape (Kessler et al. 1997). 

More research is needed in evaluating outcome 

and the role of PTSD and relapse. Women who 

relapse often are labeled as “resistant” when, in 

fact, victimizations that have not been addressed 

could account for the difficulty in stopping 

substance abuse (Root 1989). Trauma survivors 

sometimes use alcohol and drugs to medicate the 

pain of trauma and consequently are perceived 

as “treatment failures” because their trauma 

experience is misunderstood or not identifi ed 

(Covington 2008a rev., 1999a). In an outcome 

study comparing women with and without PTSD 

in treatment for substance use disorders, the 

authors found that individuals with both PTSD 

and substance use disorders relapsed more 

quickly and that PTSD was a predictor of relapse 

(Brown et al. 1996). 

While women with PTSD appear to possess more 

psychological risk factors associated with relapse 

than men, another outcome study comparing 

men and women in an outpatient treatment 

setting highlighted that women are more likely to 

engage in treatment, thereby offsetting the higher 

risks for relapse (Gil-Rivas et al. 1996). Women 

with PTSD may benefit from relapse prevention 

therapy as an effective short-term treatment for 

substance use disorders and PTSD. In a study 

evaluating the efficacy of cognitive–behavioral 

relapse prevention therapy for substance use 

disorders (only), the “Seeking Safety” program 

(manual-based treatment for substance abuse 

and PTSD), versus “standard” community 

care, women who were engaged in either relapse 

prevention therapy or the “Seeking Safety” 

program showed sustained improvement in 

substance use and PTSD symptoms at 6- and 

9-month followups in comparison to women in 

standard care (Hien et al. 2004). 

Substance abuse treatment: 

Trauma-informed treatment 

approach 

When providing treatment, clinicians need to 

be aware that most female clients are trauma 

survivors, even if they do not meet criteria for 

PTSD. During the past 20 years, the treatment 

community responded to this treatment need in 

varying ways. Several years ago, most providers 

first treated the substance use disorder then 

addressed trauma-related issues later. As 

knowledge in the field grew, collateral services 

were offered that treated substance abuse 

and trauma issues concurrently. A “traumainformed” program has an awareness of the 

pervasiveness of traumatic events and translates 

that awareness into integrated services 

that support the coping capacity of clients. 

This capacity enables a woman to stay and 

participate in treatment, to engage in a positive 

therapeutic alliance, and to learn to cope with 

the aftermath or consequences of trauma. The 

text box below provides an example of a traumainformed approach to treatment. 

A trauma-informed approach adjusts services 

to meet the needs of women who have a history 

of trauma. In 6- and 12-month outcome studies 

evaluating program and person-level effects 

among women with co-occurring disorders and 

trauma (Morrissey et al. 2005; Morrissey et 

al. 2005a), programs that provided integrated 

services (mental health, substance abuse, and 

trauma) displayed increased positive effects 

on mental health and substance use outcomes. 

Programs can use Appendix F, Integration SelfAssessment for Providers, to determine the 

extent to which their agency integrates treatment 

for substance abuse, mental illness, and trauma. 

To be trauma-informed means to know of past 

and current abuse in the life of a woman. But 

more importantly, it means to understand 

the roles that violence and victimization 

play in the lives of women seeking substance 

abuse and mental health services, to design 

integrated service systems that accommodate 

the vulnerabilities of a trauma survivor, and 

to deliver services that facilitate participation 

164 Substance Abuse Treatment for Women 
in treatment (Harris and Fallott 2001b). Being 

trauma-informed does not mean that the 

program forces clients to reveal their trauma 

unwillingly. Nor does it mean that substance 

abuse treatment counselors need the level of 

expertise that is required to help women resolve 

all their problems related to trauma. However, 

knowledge about violence against women and the 

effects of trauma helps counselors to: 

• 	Consider trauma when making assessments 

and treatment plans. 

• 	Avoid triggering trauma reactions or 

retraumatizing women. 

• 	Adjust staff behavior with clients and other 

staff members, and modify the organizational 

climate to support clients’ coping capacities 

and safety concerns. 

• 	Allow survivors to manage their trauma 

symptoms successfully so that they can access 

and continue to benefit from treatment 

services. 

• 	Emphasize skills and strengths, interactive 

education, growth, and change beyond 

stabilization. 

Clinical considerations in traumainformed services 

A history of trauma should alert counselors to 

the potential for co-occurring mental disorders, 

such as PTSD, depression, anxiety disorder, 

or personality disorders that can impede 

treatment unless addressed early. Once the 

trauma has been identified either during the 

assessment process or in early treatment, the 

The Women Embracing Life and Living (WELL) Project 

The aim of the SAMHSA-funded Women Enhancing Life and Living (WELL) Project was both 

to integrate treatment services and to encourage trauma-informed services for women with cooccurring substance use and mental disorders who have histories of violence. The project used 

relational strategies to facilitate systems change across three systems levels: local treatment 

providers, community or regional agencies, and the State government. 

Substance abuse treatment clinicians in the study reported they tended to be insensitive to 

trauma/violence issues because they were unaware of the overlap between these two issues (there 

were notable exceptions among staff at programs that were gender-specific and evidence-based). 

Clinicians who were cross-trained or attempted to provide a broader range of services to clients 

often encountered restrictions embedded in existing procedures, forms, and documentation 

requirements that made integrated care more diffi cult. 

Clients in the study recounted their frustration at having to slant their histories depending on 

the agency or practitioner they were addressing, and at having to conceal part of their histories 

to receive certain services. Rather than promoting wholeness and recovery, the experience in 

the treatment program recreated the secrecy of abuse and fed the stigma associated with their 

illnesses. 

The WELL project worked within three communities to address this fragmentation and to 

increase awareness of the importance of integrating an understanding of trauma into services 

offered to women. It began by convening leadership councils at the State and the local levels. 

Project activities included cross-training for clinicians, convening a consumer advisory group 

to provide guidance, submission of recommendations from the local leadership councils to the 

State level, and visits by consultants to each agency to assist clinicians in putting their training 

into practice. These activities resulted in greater understanding of trauma-related issues by 

clinicians, stronger linkages to community services for women with histories of trauma, and 

more referrals to these services. 

Source: Markoff et al. 2005. 

Substance Abuse Treatment for Women 165 
Note to Clinicians and Administrators 

Preliminary data support that integrated trauma-focused interventions for women in 

substance abuse treatment programs appear to be safe, thus presenting no differences in 

adverse psychiatric and substance abuse symptoms or events in comparison to standard care 

(Killeen et al. 2008). So often, clinicians and administrators fear and hold the misperception 

that addressing trauma-related issues is counterproductive and produces deleterious effects 

on women in substance abuse treatment. While the selection of services and the planning 

on how these services are delivered is important in maintaining the integrity of care for the 

client, integrated trauma-focused interventions are not only a viable option but an essential 

component of treatment for women with substance use disorders. 

counselor can begin to validate a woman’s 

experience and acknowledge that she is neither 

unique in her experience nor alone. If women 

are not questioned directly, the abuse may go 

unrecognized and untreated. Many women who 

are dependent on alcohol or drugs experience 

difficulty in recovery and relapse if violence and 

abuse issues are not addressed in treatment. 

Women may need help understanding the 

serious long-term effects of violence, sexual 

abuse, and incest on their functioning and on 

the risk of relapse (Covington 2003; Finkelstein 

1996; Najavits 2006). 

In many instances, counselors can address 

trauma and its relevance to substance abuse 

treatment effectively. In other cases, complex 

or severe problems related to trauma that 

exceed the counselor’s competence may be 

present initially or may arise during treatment. 

Clients with such problems should be referred 

to a specialist—typically a licensed mental 

health professional trained in trauma within 

the treatment program. Trauma-informed 

counselors can recognize when a therapeutic 

relationship is stretching their abilities, but the 

decision to refer a client requires understanding 

of the situation and supervisory consultation 

and agreement. 

Major trauma-related clinical issues that 

counselors need to address or attend to during 

the course of treatment include: 

• 	 Outreach. Efforts to engage women in 

treatment include flexible scheduling, ready 

availability, identification of client interest 

in and need for treatment, and ongoing 

evaluation. Outreach includes informing the 

community of services offered and initiating 

contact with agencies that should refer 

women for assessment and counseling (Elliott 

et al. 2005). 

• 	 Assessment and referral. A counselor needs 

to understand the nature of a woman’s 

exposure to trauma—the type of abuse, 

when it occurred, whether it was a one-time 

event or repeated over time, the relationship 

between the client and the perpetrator 

(family member, acquaintance, stranger), 

and what occurred if the woman previously 

disclosed the experience (Bernstein 2000). 

It requires treatment by a clinician who 

is trained in treating traumatic stress 

disorders. Women who score high on a 

posttraumatic stress assessment should be 

referred for treatment to address their PTSD 

concurrently with their substance abuse 

treatment. Counselors should be candid when 

they cannot provide the treatment the client 

needs and may need to make a referral. 

• 	Psychoeducation. One of the counselor’s 

major functions in treating a woman in 

recovery who has a trauma history is 

to acknowledge the connection between 

substance abuse and trauma. This 

acknowledgment validates a woman’s 

experience and helps her feel that she is 

not alone and that her experience is not 

shameful. Sharing prevalence data can 

reduce her sense of isolation and shame 

(Finkelstein 1996). 

• 	 Normalizing the symptoms. In addition, 

it is important to educate and discuss the 

166 Substance Abuse Treatment for Women 
Advice to Clinicians: 

When Is a Woman Ready for Trauma Processing? 

Many counselors and clients assume that “working on trauma” means telling the story 

of what happened. Although exposure therapy is a widely known treatment method 

(Foa and Rothbaum 1998), it is controversial in the substance abuse treatment fi eld. 

Questions remain about whether it is a safe treatment to conduct with clients who 

are abusing substances or engaged in self-destructive behavior. A study on exposure 

therapy for people in substance abuse treatment showed that many clients could not 

tolerate the work, with 61.5 percent not completing the minimum dose of treatment. 

Those who engaged in the treatment did well in outcomes—including reducing 

substance use and employment problems—but more research is needed to determine 

client factors that would identify who would best benefit from this type of treatment 

(Brady et al. 2001). 

Some experts recommend not asking the client to tell her story until she has achieved 

some abstinence or safe functioning, whereas others assert that this is a case-by-case 

decision. Staff and clients should not be led to believe that the “real work” is telling 

the trauma story. CBT is equally effective and may be preferred for some. Najavits 

(1998) has identified signs to determine when a woman with substance abuse disorder 

is ready for trauma-exploration work: 

• She is able to use some coping skills.

• She has no major current crises or instability (e.g., homelessness, domestic violence).

• She wants to do this type of work.

• She can reach out for help when in danger. 

• She is not using substances to such a degree that emotionally upsetting work may

increase her use. 

• Her suicidality has been evaluated and taken into account.

• She is in a system of care that is stable and consistent, with no immediate planned

changes (e.g., discharge from inpatient unit or residential program). 

typical symptoms associated with PTSD 

to help normalize the client’s physiological 

and psychological experience. Similar to 

other anxiety disorders, clients are often 

overwhelmed by symptoms leading to the 

belief that they cannot manage them or that 

they are not going to survive them. Some 

relief arrives when a client knows that they 

are having a normal reaction to an abnormal 

event or set of circumstances. 

• Safety, support, and collaboration. Trauma 

often creates profound disconnection in 

two areas: interpersonal relationships 

and internal feelings. Some women who 

experience traumas become isolated, feeling 

that the only safety is in solitude; others 

compulsively reenact dangerous relationshi

(Najavits 2002b). Alternating between the 

ps 

experience of feeling overwhelmed and 

shutting down, women come to treatment 

profoundly discouraged about the value and 

safety of relationships. For a client, safety 

is psychological and physical, internal and 

external. A major goal of treatment is to 

develop a therapeutic alliance. Ideally this 

alliance creates a safe place within which 

the woman can learn to trust and have new, 

meaningful experiences. For a substance 

abuse treatment program, safety is an 

organizational or system issue that calls for 

counselor readiness, collaboration with the 

client, staff training and supervision, and 

continual self-assessment of strengths and 

limitations (Markoff et al. 2005). 

 Tracking level of distress. Counselors need • to monitor their own and their clients’ level 

Substance Abuse Treatment for Women 167 
of distress. Counselors must observe the 

client for signs of discomfort. For example, 

if a client is hyperventilating, the counselor 

needs to help the client gain mastery of her 

breathing before proceeding. Using a scale 

of 1 to 100 to measure the client’s subjective 

units of distress (SUD scale) can be a helpful 

tool in assessing the client’s perception 

of current distress and in comparing her 

levels of distress from one session to the 

next (Wolpe 1969). It also provides tangible 

feedback to both the counselor and client. 

• Regulation of level of closeness and distance. 

Carefully maintained boundaries between 

the counselor and the client maximize the 

effectiveness of the therapeutic relationship 

and ensure that treatment does not re-create 

the original trauma. For example, counselors 

should not physically intrude on a client who 

is “shut down”—does not want to be touched. 

• Timing and pacing. The counselor addresses 

trauma issues when the woman is ready 

and functioning at a level where it is safe 

for her to explore the trauma; timing is 

directed by the client. The counselor helps 

the client identify when she is beginning to 

feel overwhelmed and how she can slow the 

process down. Trauma treatment begins 

with the start of substance abuse treatment 

and needs to be conducted in a careful and 

clinically sensitive manner. It is not always 

clear when and under what conditions it is 

helpful to a client to tell her trauma story. 

Sometimes results of this work are positive, 

but the telling can be harmful when the client 

does not yet have coping resources to handle 

the intense telling. Recalling or talking about 

her traumatic experience can retraumatize a 

woman. Even if the client wishes to talk about 

her trauma, it may be unwise if she is in an 

unstable situation (Najavits 2002a) and does 

not have a support system or is in danger of 

decompensation. 

• Coping skills. A client’s knowledge of 

coping skills helps her manage symptoms 

and increases her self-sufficiency and selfefficacy. Counselors and programs need to 

incorporate skill development components— 

including problemsolving, assertiveness, 

anger management, communications, and 

anxiety management—along with stress 

inoculation and relaxation techniques. 

Clients need to focus on both disorders and 

their interactions. More insight-oriented 

therapeutic work occurs once clients have 

attained abstinence and control over PTSD 

symptoms (Najavits et al. 1996, 2002a). 

Therapy should help women learn to use 

more healthful methods of coping with 

negative feelings, interpersonal confl ict, and 

physical discomfort (Stewart et al. 2000). 

• Affect regulation. Counselors need to assist 

clients in learning how to increase their 

tolerance for affective distress. The feeling 

of jeopardy feels real for both the client 

and counselor. It is the challenge for the 

counselor to remain connected with the 

client during this crisis, neither becoming 

overwhelmed by the traumatic reenactment 

nor emotionally abandoning the client by 

withdrawing (Cramer 2002). Training to 

handle strong feelings is essential, as is 

clinical supervision. Like the client, the 

counselor may feel shame, incompetence, 

anxiety, and anger. Emotional support from 

colleagues and supervisors helps counselors 

avoid defensiveness, client blaming, 

detachment, secondary traumatic stress 

reactions, and burnout. 

• Listening skills. A critical part of therapy 

for addressing trauma in substance abuse 

treatment is to help the client gain support 

and establish safety. Counselors need 

to be nonjudgmental, empathetic, and 

encouraging; creating an environment that 

validates the client’s experience through 

listening and gentle guidance. 

• Acknowledgment of grief and mourning. The 

client needs time to grieve many losses. While 

this grieving process begins from the outset 

of treatment, the intensity of grief reactions 

often rises as anxiety symptoms dissipate. 

• Case management. Case managers or 

counselors can assist women with solving 

problems and crisis intervention, locating 

peer-support groups and afterhours support, 

and coordinating linkages with other 

agencies. 

• Triggering and retraumatization . During 

treatment, triggering is unavoidable. A 

trigger sets off a memory of the trauma. It 

can be a noise, a television show, another 

168 Substance Abuse Treatment for Women 
person’s presence, or anything that is a 

reminder of the event. Therapist and client 

must be prepared for the difficult work of 

coping with triggers. The client is prepared 

by learning to identify the triggers and in 

either developing or enhancing coping and 

self-soothing skills. The difference between 

retraumatization and triggering is the 

therapist’s ability to stay connected to the 

affective experience of the client and the 

client’s knowledge that she will not be totally 

overwhelmed by her intense feelings (Najavits 

2002a; Russell 1998). Triggering is inevitable; 

retraumatization is not. Reenactments are 

inevitable, but if they occur under controlled 

conditions and the client feels supported and 

safe with her counselor, retraumatization 

does not have to occur. All programs need 

to be alert to the risk of triggering and 

retraumatization. 

Models of recovery 

Since the late 19th century, a number of experts 

have conceptualized recovery from trauma 

in stages, describing it in different terms but 

referring to the same process (Herman 1997). 

Most of the conceptualizations followed three 

stages. The first stage is stabilization, preventing 

further deterioration and ensuring symptom 

management. During the second stage trauma is 

remembered, reenacted, and worked through. 

Stage three is a return to normal, the time 

when the client can live with the memories 

of the trauma, and problems are controlled. 

In Trauma and Recovery, Herman (1997) 

describes trauma as a disease of disconnection 

and provides a three-stage model for recovery: 

safety, remembrance and mourning, and 

reconnection. During these stages, clients 

receive consistent support for recovery from 

their substance use disorders. 

Stage 1: Safety 

Female trauma survivors in early treatment 

for substance abuse typically need to be in an 

all-women group led by a female facilitator. 

“Survivors feel unsafe in their bodies. . . . They 

also feel unsafe in relation to other people” 

(Herman 1997, p. 160). Counselors can ensure 

that the environment is free of physical and 

sexual harassment and assess a woman’s risk 

of domestic violence. Counselors teach women 

to feel safe internally by using self-soothing 

techniques to alleviate depression and anxiety 

rather than turning to drugs (Najavits et al. 

1996). Women are helped to feel physically 

and emotionally safe in their relationships 

with their counselors. The counselor works to 

develop the client’s trust and to help her make 

the connection between substance abuse and 

victimization (Hiebert-Murphy and Woytkiw 

Advice to Clinicians: 

Retraumatization 

Some staff and agency issues that can result in retraumatization of the client include 

the following: 

• Violating the client’s boundaries 

• Breaking trust with the client

• Unclear expectations

• Inconsistent enforcement of rules

• Chaotic treatment environment

• Rigid agency policies that do not allow a woman to have what she needs to feel safe

• Disruption in routines

• Disrespectfully challenging the client’s reports of abuse 

• Labeling intense rage and other feelings about the trauma as pathological

• Minimizing, discrediting, or ignoring the client’s feelings or responses 

• Disrupting relationships because of shift changes and reassignments

• Obtaining urine specimens in a nonprivate manner

Substance Abuse Treatment for Women 169 
SAMHSA’s Women, Co-Occurring Disorders and Violence Study 

(WCDVS) 

In 1998, SAMHSA funded sites in the United States to develop integrated services for women 

who were the victims of violence and diagnosed with co-occurring mental and substance abuse 

disorders; services were also available for these women’s children. This 5-year study sought to 

compare more integrated treatment with non-integrated treatment for more than 2,000 women 

and yielded information on the effectiveness of the integrated services approach for women. 

WCDVS also addressed the interplay of substance use disorders, trauma, and mental illness 

and demonstrated the empowerment and healing that comes when female clients are involved 

directly in their care and recovery. Outcomes for women in the study improved more than the 

outcomes for those in the treatment-as-usual group when women had a voice in the planning, 

implementation, and delivery of their treatment and received counseling for all three conditions 

together. 

The study showed that to improve treatment, an increased recognition is needed of the effects 

that past and present traumas have on women in treatment. Women should be encouraged and 

helped to play an active role in their healing processes. Additional key findings include, but 

are not limited to, the following: the need for comprehensive assessment that incorporates the 

history of trauma, physical and mental health needs, and the impact of co-occurring disorders 

on child care; the need for systems change to incorporate services for women and children with 

co-occurring disorders; and that integrated services for mental health, substance abuse, and 

violence issues in a trauma-informed context appear to be more effective and not more costly 

than treatment-as-usual. 

For an overview of the study, including contact information regarding the involvement of specifi c 

programs, refer to http://www.wcdvs.com/pdfs/ProgramSummary.pdf. 

Source: Becker and Gatz 2005; Salasin 2005 

2000). The client learns to stop using unsafe 

coping mechanisms such as substance use and 

other self-destructive behaviors. An alliance 

between the counselor and the client, whose level 

of trust has been damaged by trauma, is the goal 

of this stage. 

Stage 2: Remembrance and mourning 

In this stage, women tell their stories of trauma. 

Women mourn the losses associated with their 

abuse and substance use (Hiebert-Murphy and 

Woytkiw 2000). More specifically, they mourn 

their old selves, which the trauma destroyed. 

Women stabilized in substance abuse treatment 

may be ready to begin Stage 2 trauma work. A 

counselor can address the high risk of relapse 

that exists in this phase through anticipation, 

planning, and self-soothing mechanisms 

(Najavits 2002b). Considerable clinical judgment 

is required in determining whether the client has 

adequate coping skills. 

Stage 3: Reconnection 

Once the woman has coped with past trauma, 

she can look to the future. She learns new 

coping skills, develops healthy relationships, 

and becomes oriented toward the future. Stage 

3 groups, traditionally unstructured, can be 

comprised of both women and men. This phase 

corresponds to the ongoing recovery phase of 

substance abuse treatment. For some women, 

reconnection can occur only after years of 

working through trauma issues. 

170 Substance Abuse Treatment for Women 
Note to Clinicians 

It is important to emphasize that the majority of clinical work surrounding trauma in substance 

abuse treatment programs and in early stages of recovery from substance use disorders should 

focus on safety, client skills in establishing safe behaviors, and early trauma recovery skills— 

specifically coping skills such as grounding, emotional regulation, and stress management 

strategies. 

Treatment programs and curricula 

for substance use disorders and 

trauma 

The following trauma-specific curricula are 

designed to address treatment issues with women 

who have a history of trauma and traumarelated symptoms and substance abuse. These 

programs are mainly focused on establishing 

safety and support, providing psychoeducation, 

and developing coping strategies and skills 

surrounding the sequelae of trauma and 

substance use disorders (for review of integrated 

trauma treatment models see Finkelstein et al. 

2004 and Moses et al. 2003). 

The Addiction and Trauma Recovery 

Integration Model (ATRIUM; Miller and Guidry 

2001): Based on Miller’s Trauma Reenactment 

Model, ATRIUM is a 12-week program that 

integrates psychoeducational and expressive 

activities for individuals with trauma-related 

and substance use problems. The ATRIUM 

model assesses and intervenes at the body, mind, 

and spiritual levels and addresses issues linked 

to trauma and substance abuse experiences 

such as anxiety, sexuality/touch, self-harm, 

depression, anger, physical complaints 

and ailments, sleep problems, relationship 

challenges, and spiritual disconnection. 

Beyond Trauma: A Healing Journey for 

Women and A Healing Journey: A Workbook 

for Women (Covington 2003a, b): The theme of 

this 11-session integrated program for trauma 

treatment is the connection between substance 

abuse and trauma in women’s lives. It includes 

a psychoeducational component for teaching 

women about trauma and its effects on the inner 

self (thoughts, feelings, and beliefs) and the 

outer self (behavior and relationships, including 

parenting). The program emphasizes coping 

skills, cognitive–behavioral techniques, and 

expressive arts, and is based on the principles 

of relational therapy. It includes a facilitator’s 

manual, participant’s workbook, and videos. 

Helping Women Recover: A Program for 

Treating Addiction (Covington 2008a, b rev., 

1999a, b): This 17-session step-by-step guide 

integrates the theoretical perspectives of 

substance abuse and dependence, women’s 

psychological development, and trauma in 

four modules (self, relationships, sexuality, 

and spirituality). The program includes a 

facilitator’s guide to work with such issues as 

self-esteem, sexism, family-of-origin, support 

system, mothering, and self-soothing issues. 

A Woman’s Journal provides self-tests and 

exercises to help clients with substance use 

disorders create personal guides to recovery. 

There is a separate version for women in the 

criminal justice system (Covington, 2008a, b 

rev., 1999a, b). 

Seeking Safety (Najavits 2000, 2002b, 

2004, 2007): This manual-based, cognitive, 

behavioral, and interpersonal therapy model for 

substance use disorders and PTSD focuses on 

client safety. It can be conducted in individual 

or group formats. The manual includes 25 topics 

and is based on fi ve principles: 

1. Safety as the priority of this “fi rst stage” 

treatment 

2. Integrated treatment of PTSD and substance 

use disorder 

3. A focus on ideals 

4. Four content areas: cognitive, behavioral, 

interpersonal, and case management 

5. Attention to therapist processes 

Several outcome studies have been completed 

on Seeking Safety, all showing positive results. 

The studies involve the following populations: 

women treated in an outpatient setting using a 

Substance Abuse Treatment for Women 171 
Note to Clinicians 

Key issues in treatment for trauma-related mental disorders have been how, when, and 

whether to encourage clients to address trauma intensively during the course of substance 

abuse treatment. Most clinicians believe that a woman needs to achieve a basic level of safety 

before moving on to detailed trauma processing. The counselor should consider carefully the 

client’s level of readiness for this type of work; the client’s symptoms may worsen if she engages 

prematurely in such exploration (Herman 1997). In one study, interventions were adapted 

to combine exposure therapy with the “Seeking Safety” program; clients with substance use 

disorders were encouraged to move in and out of trauma processing, balancing it with training in 

coping skills and building in specific safety parameters (Najavits et al. 2005). 

group modality (Najavits et al. 1998); women in 

prison in a group modality (Zlotnick et al. 2003); 

low-income and mostly minority women in 

individual format (Hien et al. 2004); adolescent 

girls (Najavits et al. 2006); and women in a 

community mental health setting in group 

format (Holdcraft and Comtois 2002). In a study 

that targeted patient and counselor feedback 

(Brown et al. 2007), results show that clinicians 

and clients alike were satisfied and felt that the 

Seeking Safety program was relevant to the 

treatment program and clients’ needs. Seeking 

Safety has been implemented in a variety of 

clinical programs in addition to these research 

studies. 

Trauma Adaptive Recovery Group Education 

and Therapy (TARGET; Ford et al. 2000): 

TARGET assists clients in replacing their stress 

responses with a positive approach to personal 

and relational empowerment. The curriculum 

includes a one- to three-session orientation, a 

five- to nine-session core education and skills 

curriculum, and 26 sessions of applications of 

recovery principles. TARGET has been adapted 

for clients who are deaf and for those whose 

primary language is Spanish or Dutch. TARGET 

is being evaluated in several treatment settings. 

Trauma Recovery and Empowerment 

Model (TREM; Harris and The Community 

Connections Trauma Work Group 1998): This 

33-session group approach was developed by 

clinicians with considerable input from clients 

and includes survivor empowerment, power 

support, and techniques for self-soothing, 

boundary maintenance, and solving problems to 

be covered over 9 months. TREM assists women 

with the trauma recovery process and includes 

social skills training, psychoeducational and 

psychodynamic techniques, and peer support 

groups. Each section includes discussion 

questions, typical responses, and experiential 

exercises (Harris and The Community 

Connections Trauma Work Group 1998). TREM 

is being evaluated in several treatment settings. 

Preliminary studies showed symptom reduction 

and client satisfaction (Berley and Miller 2004). 

Treating Addicted Survivors of Trauma (Evans 

and Sullivan 1995): Combining therapeutic 

approaches with a 12-Step approach to the 

treatment of substance use disorders, this model 

for treatment of survivors of childhood abuse 

who have substance use disorders is based on 

a medical view of substance abuse as illness. It 

assumes clients accept the 12-Step approach, 

uses the principle of safety first to drive all 

interventions, and has five stages to organize the 

selection and timing of treatment tactics: crisis, 

skills building, education, integration, and 

maintenance (Sullivan and Evans 1994). 

Substance Dependent PTSD Therapy (SDPT; 

Triffleman 2000): This integrated approach 

showed positive outcomes in a small controlled 

pilot study that compared it with 12-Step 

facilitation therapy. SDPT is a 5-month, 

two-phased, individual CBT method using 

relapse prevention and coping skills training, 

psychoeducation, stress inoculation training, 

and exposure treatment for PTSD. Participants 

meet twice weekly. The use of the combined 

approaches for PTSD treatment techniques with 

clients with substance use disorders is notable. 

The first phase incorporates understanding and 

education about PTSD symptoms as part of 

the overall approach to abstinence. The second 

172 Substance Abuse Treatment for Women 
phase continues work on substance-related 

abstinence, while primarily targeting PTSD 

symptoms. In clinical trials, this model showed 

equal success rates in women and men. 

Mood Disorders 

Depression 

Major depression is an intense, acute form of 

depression, often with physiological changes 

in such areas as sleep, appetite, energy level, 

and ability to think. Thought content includes 

feelings of worthlessness and suicidal ideation 

or plans, although older adults and people from 

some ethnic groups or cultures sometimes do 

not express this cognitive component. Major 

depression has severe, moderate, and mild 

variants. Even mild major depression is a 

serious mental disorder. 

Major depressive episodes and dysthymia are 

present in nearly twice as many women as men 

for both lifetime and 12-month prevalence. 

Research suggests that women experience more 

chronicity of depression in comparison to men 

characterized by earlier onset of symptoms, 

poorer quality of life, greater social impairment, 

and greater familial history of mood disorders 

(Kornstein et al. 2000). 

Although rates of depression among women of 

color in the general population are comparable 

with those for Caucasian women, the illness is 

more likely to be undiagnosed and untreated in 

the former group, according to the literature 

reviewed (Mazure et al. 2002). Depression may 

appear through somatic symptoms that are 

misinterpreted by providers. Of concern is the 

lack of compliance with treatment regimens 

using psychotropic medications by women of 

color, which is possibly related to side effects 

of the medication. In addition, the sense of loss 

associated with migration may contribute to 

high levels of depression among Hispanic/Latina 

and Asian and Pacifi c-Islander immigrant 

women. In a study examining the use of 

pediatric emergency services with a sample of 

Mexican- and Central-American immigrants in 

Los Angeles, the women reported high levels of 

mental distress (Zambrana et al. 1994). Somatic 

complaints are common among Hispanic/Latinas 

and can mask depression or other mental illness. 

Women with substance use 

disorders and depression 

Alcohol consumption and alcohol-related 

problems co-occur with depression more often 

in women than in men (Graham et al. 2007). 

Depression usually precedes alcohol abuse in 

women, whereas alcohol dependence usually 

comes first among men (Moscato et al. 1997). 

Two mechanisms have been suggested to explain 

the pattern among women: (1) alcohol is used to 

try to relieve the symptoms of depression, and 

(2) depression renders women less concerned 

about issues of health and safety, including 

alcohol consumption (Dixit and Crum 2000). For 

more in-depth information on depression, refer 

to the TIP 48 Managing Depressive Symptoms 

in Substance Abuse Clients During Early 

Recovery (CSAT 2008). 

One study indicates that the risk for heavy 

drinking is higher among women with a history 

of depressive disorder than among women 

with no history of depression, and the risk for 

heavy drinking rises with increasing reports of 

depressive symptoms (Dixit and Crum 2000). 

Research suggests that genetic factors contribute 

to women’s susceptibility to both disorders. 

Among treatment-seeking women, depression is 

positively correlated with craving (Zilberman 

et al. 2003). While craving is not consistently 

associated with relapse, clients who experience 

cravings express distress in managing and coping 

with them. 

Although it may be difficult to determine 

whether the depression or substance use 

disorder is primary, both need to be identifi ed 

and treated concurrently to minimize relapse 

and improve a client’s quality of life. If a 

woman’s depression is life threatening, the 

depression must be treated immediately. In 

general, the disorder with the higher crisis 

potential needs to be addressed fi rst—but 

neither should be neglected. Withdrawal 

symptoms sometimes include depression, 

Substance Abuse Treatment for Women 173 
and withdrawal symptoms sometimes mask 

depression. Appropriate treatment requires a 

thorough history and monitoring of symptoms 

over time. 

Substance abuse treatment and 

depression 

Women with co-occurring substance use 

disorders and depression can be placed in a 

variety of treatment settings, depending on the 

severity of their disorders. Antidepressant and 

mood-regulating medications are appropriate 

for women in treatment for both disorders. 

Clients may require medication to overcome 

debilitating and incapacitating depressive 

symptoms so that they can participate in 

substance abuse treatment. In addition, relief 

from depression can be significant motivation in 

recovery. However, it may take time for a client 

to be stabilized on the appropriate medication 

and dosage. Women may need education and 

medication monitoring initially to ensure they 

are taking their medications as prescribed. Some 

women may increase their dose thinking that the 

larger dose provides more help or reduce their 

dose to prove they are improving. Still other 

women may have difficulty taking antidepressant 

medication based upon fear and misinformation 

that it is addictive. 

SSRIs and other new generation antidepressants 

often are used because their improved side effect 

profile increases the likelihood of compliance 

(Zweben 1996). Women with depression may 

respond to a combination of psychotherapy and 

medication. CBT and interpersonal therapies 

(IPT) are evidence-based approaches in treating 

depression (Butler et al. 2006; deMello et 

al. 2005; Kuyken et al. 2007), and they can 

be used as an adjunct to medication or as a 

principal intervention for mild or moderate 

depression. For clients who are hesitant to 

use medications or when the use of medication 

is contraindicated, CBT and IPT are viable 

options but appear far less effective when 

depression is severe (Luty et al. 2007; Markowitz 

2003). 

Eating Disorders 

Between 90 and 95 percent of those diagnosed 

with eating disorders are women (Hoek 1995), 

with as many as 5 percent of young women being 

affected (Frank et al. 1998). Studies have shown 

that bulimia affects between 2 and 5 percent of 

women, whereas anorexia is much less common 

(Frank et al. 1998). About 2 percent of the U.S. 

population has a binge eating disorder, and it 

occurs in 10 to 15 percent of mildly obese people 

(National Institute of Diabetes and Digestive 

and Kidney Diseases 2001). However, all 

measures of the prevalence of eating disorders 

are considered to be estimates by researchers 

because they represent only cases diagnosed in 

medical facilities. Women with eating disorders 

are skilled at concealing their disorders and 

many remain undiagnosed (Hoek and Van 

Hseken 2003). Common definitions of eating 

disorders and behaviors are defi ned in 

Figure 7-4. 

Substance abuse counselors and mental health 

professionals have difficulty detecting eating 

disorders because clients minimize or deny 

their symptoms and fail to seek treatment out 

of shame or fear of gaining weight. Counselors 

should be alert to symptoms of eating disorders 

that may be serious but do not meet full criteria 

for an eating disorder diagnosis. Disordered 

eating behaviors can pose serious health issues 

and lead to full-blown disorders. In addition, 

counselors should be aware that eating disorders 

occur in women from diverse backgrounds. 

Note to Clinicians 

Women receiving methadone maintenance treatment (MMT) require antidepressant medication 

that is compatible with methadone, but dosages of both need close monitoring. Although MMT 

can normalize mood in some women, it is a treatment for opioid dependence, not depression 

(Zweben 1996). TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment 

Programs (CSAT 2005b), provides more information. 

174 Substance Abuse Treatment for Women 
Figure 7-4 

Common Definitions of Eating Disorders and Behaviors 

Anorexia nervosa is self-starvation. Women with this disorder eat very little even though they 

are thin. They have an intense and overpowering fear of body fat and weight gain. 

Bulimia nervosa is characterized by cycles of binge eating and purging, by either vomiting or 

taking laxatives or diuretics (water pills). People with bulimia have a fear of body fat even 

though their size and weight may be normal. 

Overexercising is exercising compulsively for long periods to burn calories from food that has 

just been eaten. Women with anorexia or bulimia may overexercise. 

Binge eating means eating large amounts of food in short periods, usually when alone, without 

being able to stop when full. The overeating or bingeing often is accompanied by feeling out of 

control and is followed by feelings of depression, guilt, or disgust. 

Disordered eating refers to troublesome eating behaviors, such as restrictive dieting, bingeing, 

or purging, which occur less frequently or are less severe than those required to meet the full 

criteria for the eating disorder diagnosis. 

Source: Adapted from HHS, Office on Women’s Health 2000b. 

Although anorexia is seen most often in young 

heterosexual Caucasian women, girls and women 

from all ethnic and racial groups have eating 

disorders and disordered eating at increasing 

rates. Often these women receive treatment 

for the accompanying symptoms of an eating 

disorder, such as depression, rather than 

for the disorder itself. When they are fi nally 

diagnosed, the disorder tends to be more severe 

(HHS, Office on Women’s Health 2000). Overall, 

studies show that eating disorders are positively 

associated with all DSM-IV mood, anxiety, 

impulse-control, and substance use disorders 

regardless of age, gender, and race-ethnicity 

(Hudson et al. 2007). 

Women with substance use and 

eating disorders 

One study evaluating the role of eating disorder 

behaviors and its association with substance 

use (Piran and Robinson 2006) determined 

that as eating disorder behavior becomes more 

severe, the number of substance classes used 

increases as well. Specifically, severe bingeing 

was consistently associated with alcohol 

consumption, and dieting and purging was 

associated with stimulant and sleeping pills/ 

sedative use. Herzog and colleagues found that 

17 percent of women seeking treatment for 

either anorexia nervosa or bulimia nervosa had 

a lifetime drug use disorder (Herzog et al. 2006). 

Overall, research indicates that substance abuse 

is accompanied more often by bulimia and 

bulimic behaviors than by anorexia (Bulik et 

al. 2004; Holderness et al. 1994; Ross-Durow 

and Boyd 2000). Nearly one third of women 

with a history of bulimia also have a history of 

alcohol abuse, and 13 percent have a history 

of alcohol dependence. Alcohol abuse and 

dependence have been found to be related to 

PTSD and major depressive disorder, which in 

turn were associated with bulimia. One study 

demonstrated that alcohol use disorders are 

highly prevalent among women with bulimia 

and that the presence of PTSD and depression 

increases the risk of alcohol abuse occurring 

(Dansky et al. 2000). 

Attitudes toward dieting among young women 

may be related to increased susceptibility to 

alcohol and drug use (Zweben 1996). This is 

both a health issue and a relapse risk because 

some women may use cocaine or amphetamines 

(or both) to manage their weight. Additionally, 

the tendency to overeat affects many women in 

Substance Abuse Treatment for Women 175 
early recovery. Compulsive or binge eating bears 

a similarity to abuse of substances other than 

food and is correlated with depression, thoughts 

of suicide, and childhood sexual abuse. Women 

engaging in binge eating sometimes use food as 

a substitute addiction; others may overeat to 

compensate for the stress they experience in 

early abstinence. Elements of the eating disorder 

take the place of relapsing to the drug of choice 

(Ross 1993). 

Eating disorders need to be viewed in a 

biopsychosocial context that addresses 

biological or organic factors, a social component 

(influence of media and other cultural images 

enforcing standards of slimness for women), 

and psychological issues. Eating disorders are 

correlated with growing up in dysfunctional 

families where substance abuse occurs (van 

Wormer and Askew 1997). A strong relationship 

exists between eating disorders and depression, 

self-inflicted violence, and suicidal tendencies 

(APA 2000a; Kuba and Hanchey 1991). Most 

women with eating disorders meet DSM-IV 

criteria for at least one personality disorder, 

such as borderline, histrionic, or obsessive– 

compulsive personality (Zerbe 1993). 

Eating disorders are sometimes present before 

the onset of alcohol and drug problems and 

can be obscured by active substance use, or 

they may be inactive during periods of active 

drinking or drug abuse. Eating disorders can 

precede the onset of substance use disorders 

chronologically, follow them, or develop 

simultaneously (Bulik and Sullivan 1998). A 

history of bulimia, anorexia, or compulsive 

overeating could become a barrier to the 

successful treatment of a client’s substance 

use disorder if the prior eating disorder goes 

undetected. Deprived of compulsive involvement 

with food, a woman may begin to abuse 

substances. During treatment for substance use, 

unbeknownst to the therapist, the disordered 

eating behavior may reappear. Because the 

eating disorder takes over the function of the 

substances by helping the client cope, a cycle 

can occur that never addresses the common 

and predisposing factors contributing to both 

problems. There may be success in that the 

substance use has stopped; however, this may 

be a result only of disordered eating or symptom 

substitution. This disordered use of food masks 

depression, anxiety, and other symptoms 

expected to surface during the treatment of 

substance use, leaving the therapist with no 

view of the woman’s coping abilities without any 

compulsive and disordered behavior. Eating 

disorders may coexist with alcohol and drug 

consumption in other ways (John et al. 2006). 

Diuretics, laxatives, emetics, stimulants, heroin, 

tobacco, and thyroid hormone may be attractive 

to a woman with anorexia or bulimia because 

of their weight-loss potential or their ability to 

facilitate vomiting (Bulik and Sullivan 1998). 

Substance abuse treatment and 

eating disorders 

Therapeutic modalities include individual, 

group, and family therapies. A cognitive– 

behavioral approach is used to address the 

irrational thoughts that lead to disordered 

eating behaviors (van Wormer and Askew 

1997). CBT has been effective for women with 

bulimia in reducing the frequency of binge/purge 

cycles and improving body image, mood, and 

social functioning. In some instances, the use of 

tricyclic antidepressants and selective serotonin 

reuptake inhibitors can improve short-term 

outcomes, but in all eating disorder cases, 

medical evaluation should be included (Carr and 

McNulty 2006; Raeburn 2002). 

Interpersonal therapy has been used 

successfully with women with bulimia, and 

dialectical behavior therapy recently has begun 

to be used with this population (Raeburn 

2002; Safer et al. 2001). Additional treatment 

approaches for women with eating disorders 

that can engage clients include psychoeducation, 

behavioral contracting, and nutrition 

monitoring (Frank et al. 1998). 

176 Substance Abuse Treatment for Women 
Treating this condition requires specialized 

training, along with a thorough medical 

evaluation for problems typically associated 

with eating disorders. Clients require nutritional 

counseling to develop healthful eating patterns, 

medications (usually antidepressants), and 

discharge planning that addresses both eating 

and substance use disorders (Marcus and Katz 

1990). Eating disorders often surface or are 

exacerbated when women reduce substance 

use; in this situation, integrated care and 

management is the optimal choice. 

It is important for counselors to look beyond 

the earlier profiles of eating disorder cases 

and consider symptoms among women of color 

and in various social classes. The HHS Offi ce 

on Women’s Health provides educational 

materials on eating disorders on its Web site 

(www.4women.gov/BodyImage). 

Addressing Tobacco Use 

With Women in Treatment 

Cigarette smoking is a major cause of lung 

cancer among women. Approximately 90 percent 

of all lung cancer deaths are attributable to 

smoking. Since 1950, lung cancer mortality 

rates for American women have increased an 

estimated 600 percent. In 1987, lung cancer 

surpassed breast cancer to become the leading 

cause of cancer death among American women. 

In 2000, about 27,000 more women died of lung 

cancer (67,600) than breast cancer (40,800; 

CDC 2001). In 2004, diseases caused by cigarette 

smoking killed an estimated 178,000 women in 

the United States. The three leading diseases 

were lung cancer (45,000), chronic lung disease 

(42,000), and heart disease (40,000; CDC 2005). 

Although it is commonly accepted in the 

substance abuse treatment field that the use of 

one addictive drug frequently leads to relapse 

Advice to Clinicians: 

Women With Eating Disorders 

Substance abuse counselors may want to consider these steps in addressing eating 

disorders: 

• Include an eating history as part of a comprehensive assessment of a client (refer to

chapter 4 on Screening and Assessment). 

• Refer for medical evaluation.

• Ask the client what happens as a result of the disordered eating behaviors. Does she

feel in control, more relaxed, or numb? Approach eating disorders as a response to 

emotional discomfort. 

• Educate the client about eating behaviors as a legitimate health concern.

• Develop integrated services, and coordinate necessary services and referrals (including

a referral to a provider that specializes in eating disorder treatment). 

• Incorporate nutritional counseling and psychoeducation on eating disorders and

disordered eating. 

• Institute routine observations at and between meals for disordered eating behaviors.

• Recommend the use of support groups that are designed specifically for the given 

eating disorder. 

• Teach coping skills using cognitive–behavioral therapy and include anxiety 

management training. 

Source: Bulik and Sullivan 1998; Rome 2003 

Substance Abuse Treatment for Women 177 
to a person’s “drug of choice,” this has not 

been clarified in the issue of nicotine use and 

substance abuse (Burling et al. 2001). Many 

treatment professionals have thought it too 

difficult for clients to give up tobacco and still 

remain abstinent from other substances even 

after years of being drug or alcohol free. They 

believed that any attempt to stop smoking could 

put the recovering person at an increased risk 

for relapse. It also was assumed that people 

will quit naturally if they so desire (Bobo et al. 

1986). 

However, research and experience since the mid1980s has begun to challenge these assumptions 

(for review, see Prochaska et al. 2004; Sussman 

2002). Research shows that quitting smoking 

does not jeopardize substance abuse recovery; 

that nicotine cessation interventions in 

substance abuse treatment are associated with 

an increase in long-term abstinence of alcohol 

and illicit drugs. Prochaska and colleagues 

(2004) examined outcomes of smoking cessation 

interventions in 19 randomized controlled 

trials with individuals both in current addiction 

treatment and in recovery. The researchers 

found striking interactions between smoking 

cessation and success in treatment for other 

drug abuse. Their first observation was that 

among both men and women, those who stopped 

smoking while also quitting other drug use 

showed higher success rates in abstinence from 

alcohol and other drugs, even though their rates 

of relapse to cigarette use was high. 

Motivating women to stop smoking involves 

addressing their concerns about the diffi culties 

and negative consequences of smoking cessation 

and bolstering their confidence to stop (Miller 

and Rollnick 2002). Women’s motives for 

stopping smoking include their present health, 

their future health, and the effect of their 

smoking on the health of others. Women’s 

concerns about quitting include believing 

stopping will be difficult, feeling tense and 

irritable if they quit, enjoying smoking too much 

to stop, expecting difficulty concentrating after 

quitting, and anticipating gaining considerable 

weight after stopping (Lando et al. 1991; 

Pomerleau et al. 2001). Studies have not 

consistently shown differences in relapse rates 

between men and women, yet women appear to 

have higher rates of relapse when they fail to 

adhere to pre-established quit dates (Borrelli et 

al. 2004). Among women, relapse is signifi cantly 

related to weight gain, strong negative affect, 

history of depression, family history of smoking, 

unemployment, and a history of smoking 

cigarettes high in nicotine (Cooley et al. 2006; 

Hoffman et al. 2001; Swan and Denk 1987; 

Wetter et al. 1999). 

Akin to other services, smoking cessation 

programs should be integrated into substance 

abuse treatment for women. Providers are 

encouraged to include smoking cessation in their 

clients’ treatment plans, as this will help send 

a message to women that treatment providers 

care about their total health. Further, even 

temporary cessation from smoking (assisted 

with nicotine replacement therapy) may give 

women confidence about remaining abstinent 

from other substances, and there may be no 

other opportunity to help them quit smoking. 

In reviewing the common relapse risks among 

women, nicotine cessation programs should 

consider strategies (along with pharmacologic 

therapies), that address body image, nutritional 

counseling, and emotional regulation combined 

with CBTs that target cognitions, establish 

quit dates, and teach coping strategies to 

manage anticipated difficulties in maintaining 

abstinence. 

The consensus panel believes that smoking 

cessation programs should be offered in all 

substance abuse treatment programs. Clinics 

can meet a minimum standard of care by 

adopting some of the following guidelines: 

• 	 Require all treatment facilities to be smoke 

free, and provide nicotine cessation programs 

for employees as well. 

• 	Provide onsite cessation services and include 

tobacco and nicotine issues as part of 

treatment planning. 

• 	Train staff to address nicotine addiction. 

Substance abuse counseling skills already in 

place can be applied to help clients achieve 

and maintain smoking cessation. 

178 Substance Abuse Treatment for Women 
• Base counseling sessions on professional 

guidelines for smoking cessation, such as 

those supported by the National Cancer 

Institute and the U.S. Public Health Service. 

• Provide all clients access to pharmacotherapy 

as an aid in quitting tobacco use; for 

example, nicotine patches and nasal sprays, 

bupropion (ZybanTM), and varenicline 

(ChantixTM), if medically appropriate. Note 

that few studies have examined the risks 

associated with nicotine replacement and 

other pharmacotherapies among pregnant 

women (for review, see Schnoll et al. 2007; 

Wise and Correia 2008). 

• Identify local resources for referrals for 

more intensive interventions, such as the 

American Cancer Society (www.cancer.org) 

and the American Heart Association (www. 

americanheart.org). 

Substance Abuse Treatment for Women 179 
In This
 

Chapter
 

Continuing Care
 

Treatment Outcome
 

Support Systems for 


Women
 

Administrative 


Considerations
 

8 Recovery 

Management and 

Administrative 

Considerations 

Overview 

The first part of this chapter, aimed at the substance abuse 

treatment counselor, examines the most critical aspects of recovery management including continuing care services, outcome 

and relapse variables, and support services. The second part 

is directed toward substance abuse treatment program administrators and supervisors. This segment looks at the benefi ts of 

consumer participation in programming, the characteristics of 

a healing environment for treatment, and the main components 

of staff development including staffing, training, and clinical 

supervision specific to women’s programming. Organizational 

change strategies that focus on how an organization can become 

gender responsive follow. 

Continuing Care 

Continuing care services, often referred to as aftercare, are substance 

abuse services that occur after initial treatment. Continuing care is 

designed to provide less intensive services as the client progresses in 

treatment and establishes greater duration of abstinence. The dearth 

of research on continuing care is particularly evident surrounding 

gender differences. Several studies are available that show potential 

patterns, but caution is needed in interpreting the findings due to 

methodological issues and sample size. 

Although women appear more likely to attend aftercare, any 

transition from one service to the next can be challenging for the 

client and treatment provider (Carter et al. 2008). In general, clients 

are more likely to discontinue treatment during these periods. Women 

Recovery Management and Administrative Considerations 181 
often express feelings of disconnection with 

the new treatment provider and experience 

additional struggles in managing the added 

demands and expectations of child care while 

attending less intensive treatment. Relapse is 

more prevalent during these periods, especially 

when there is little compliance or support from 

family to follow aftercare plans. The initial risk 

factors that served as a direct or indirect path 

to substance use often are the same risk factors 

that reappear in early recovery and sabotage 

involvement in continuing care, recovery 

activities, and abstinence. As an example, 

women who have a history of substance use 

that involves a significant relationship appear 

more likely to leave care prematurely due to the 

influence of a boyfriend, spouse, or signifi cant 

other. 

In one study that gained information from 

program case managers, it was reported that 

the women who had prior inadequate drug 

treatment services were most likely to drop out 

of continuing services (Coughey et al. 1998). 

Those women who completed aftercare had two 

times the amount of prior residential alcohol/ 

drug treatment and longer sobriety time at 

admission. Equally important, women appear 

more likely to engage in continuing care if 

the primary treatment they received involved 

specialized programming for women (Claus et al. 

2007). 

Treatment Outcome 

Historically, researchers have used 

posttreatment abstinence rates as the focal 

point of measuring success. Debate has 

ensued regarding how to measure treatment 

outcome and whether or not posttreatment 

abstinence rates are myopic in that they fail 

to account for the physical, psychological, 

and social conditions that improve in the 

treatment process. Other commentaries have 

suggested that using abstinence rates as the 

only benchmark to measure outcome falls 

short of recognizing the chronic nature of 

substance dependence disorders––that relapse 

is not inevitable but a likely event that can 

provide a client with a learning opportunity 

to strengthen recovery skills. Overall, most 

outcome studies have targeted more immediate 

responses to treatment, often measuring and 

following outcome variables no longer than 12 

months beyond discharge (Grella et al. 2005). 

This section examines the many factors that 

contribute to treatment outcome and includes 

numerous studies that expand the defi nition 

of treatment outcome beyond abstinence 

rates, including quality of life and other 

biopsychosocial benefits. The segment ends 

with a discussion on relapse and prevention for 

women, and specifically for postpartum women. 

Gender is not a significant predictor of 

treatment outcome. Once in treatment, women 

are as likely as men to complete treatment 

and have good treatment outcomes, although 

outcome differences are noted when evaluating 

individual and program characteristics 

(for a comprehensive literature review, see 

Greenfield et al. 2007a). Women are also as 

likely to have similar abstinence rates and 

overall quality of life 1 year after discharge 

from treatment (Slaymaker and Owen 2006). 

As shown by previous research (Timko et al. 

2002), women show greater increases than 

men in employment, recovery-oriented social 

support systems, and participation in selfhelp groups (Grella et al. 2005). Grella’s study 

found that women have greater reduction 

in levels of distress, although their levels of 

distress appear to remain consistently higher 

than those of their male counterparts at each 

period of outcome evaluation. For women 

with posttraumatic stress reactions, literature 

supports the relationship between the receipt 

of integrated trauma treatment services and 

positive treatment outcome (Cohen and Hien 

2006; Cocozza et al. 2005). In a posttreatment 

outcome study measuring factors that predicted 

5-year abstinence, 12-Step participation and 

involvement in social networks that support 

recovery were among the essential ingredients 

(Weisner et al. 2003a, b). 

Although further evaluation is needed, there 

appears to be a stronger association between 

treatment participation and posttreatment 

outcome among women (Fiorentine et al. 1997; 

182 Recovery Management and Administrative Considerations 
Hser et al. 2004). Literature suggests that 

treatment completion and length of stay in 

residential treatment are important factors in 

establishing positive posttreatment outcomes 

among women (Greenfield et al. 2004). Specifi c 

posttreatment outcome analysis comparing 

length of treatment to posttreatment outcome in 

residential treatment for pregnant and parenting

women and their children shows an association 

between longer lengths of stay and abstinence, 

improvements in employment and income, 

decreases in arrests and depressive symptoms, 

and more positive attitudes toward parenting 

(Conners et al. 2006). Although studies have 

begun to shed light on gender differences in 

posttreatment outcome, future research should 

continue to examine the specifi c underlying 

factors that influence treatment outcomes 

and how these factors differ between men and 

women. 

Relapse 

Gender alone does not predict substance 

abuse treatment outcomes. Instead, client 

characteristics are more likely to predict 

relapse, and these characteristics often infl uence 

the risk of relapse differently in men and women 

(Greenfield et al. 2007b). Women who complete 

treatment for substance use disorders show 

no significant differences in relapse rates or 

only slightly better outcomes compared with 

men (for review, see Walitzer and Dearing 

2006). However, gender 

differences do emerge 

across qualitative and 

quantitative studies that 

evaluate antecedents or 

risk factors associated 

with relapse and the 

clients’ psychological 

and behavioral reactions 

to the relapse. Relapse 

characteristics and 

reactions specifi c to 

women are highlighted in 

Figure 8-1 (p. 184). 

Currently, many relapse 

prevention programs 

do not delineate 

specific strategies and 

therapeutic approaches 

for women. Thus, 

research is needed 

to develop and evaluate relapse prevention 

programs and intervention strategies for 

women. One randomized study is available that 

evaluates a manual-based, women-only, womenoriented relapse prevention therapy group 

called Women’s Recovery Group (WRG). In this 

study, WRG produced better outcomes in the 6 

months following treatment than a mix-gender 

group using a standard manual-based program 

(Greenfield et al. 2007b). A forthcoming book by 

Greenfield, to be published by Guildford Press, 

Women are as likely 

as men to experience

positive treatment

outcomes including

similar abstinence 

rates and overall 

improvement in

quality of life.

Note to Clinicians: 

Family Reunifi cation 

The ability to regain custody of children can significantly motivate mothers to not only enter and 

pursue treatment but also to maintain motivation for ongoing recovery after treatment. Mothers 

in early recovery can face numerous challenges and stressors associated with reunifi cation, 

including time pressures in establishing recovery to avoid termination of parental rights, the 

maintenance of recovery activities while assuming the parenting role, the management of affect 

associated with the impact of their past drug and alcohol use on their children’s physical and 

mental health, effective implementation of parenting skills, and others (for review, see Carlson et 

al. 2006). As a provider, it is important to not only acknowledge the mother’s initial enthusiasm 

and motivation for reunification, but also incorporate preparatory skills, including parenting, 

stress and anger management, and problemsolving to help fortify personal resources in 

anticipation of future parenting and childcare issues and challenges. 

Recovery Management and Administrative Considerations 183 
will provide the protocol for this women-specifi c 

relapse prevention group. Figure 8-2 provides 

examples of topics discussed in WRG. 

Postpartum relapse prevention 

It is not uncommon for women who abstained 

from alcohol, drugs, and tobacco during 

pregnancy to return to use after childbirth 

(Mullen 2004). The stresses of parenting a 

newborn and the resumption of activities 

curtailed during pregnancy can involve a host 

of triggers. The postpartum period presents 

numerous triggers for relapse in recovering 

women who are drug dependent, including: 

• 	 Pain and other common discomforts of the 

postpartum period. 

• 	 Fatigue and sleep deprivation. 

• 	 Other chronic health problems. 

• 	The stress of role adaptation and caring for a 

newborn (along with other children for some 

women). 

• 	 Shifts in relationships with partners and 

family members. 

• 	Interactions with child welfare agencies, 

courts, and criminal justice agencies. 

• 	Ambivalence about parenting. 

• 	Temporary or permanent loss of custody, 

whether voluntary or involuntary. 

• 	 Reunification after temporary loss of infant 

custody. 

• 	 Guilt and grief related to infant illness or 

death. 

• 	 Other stressors of daily living. 

Figure 8-1 

Women-Specific Predictors of Relapse and Reactions to Relapse 

Relapse Risks Unique to Women 

Women are more likely to relapse if they report or display: 

• 	 Interpersonal problems and confl icts. 

• 	 Low self-worth that is connected to intimate relationships. 

• 	 Severe untreated childhood trauma. 

• 	 Strong negative affect. 

• 	 More symptoms of depression. 

• 	 Greater difficulty in severing ties with other people who use. 

• 	 Failure to establish a new network of friends. 

• 	 Lack of relapse prevention coping skills. 

Women’s Reactions to Relapse 

Women are more likely than men to exhibit the following behaviors during or after relapse: 

• 	 Relapsing in the company of others and particularly with female friends or a signifi cant other. 

• 	 Escalating use after initial relapse that is positively associated with severity of childhood 

trauma. 

• 	 Seeking help. 

• 	 Experiencing slightly shorter relapse episodes. 

• 	 Reporting depressed mood. 

Women are less likely than men to be affected by the same relapse risks across multiple relapse 

episodes. 

Source: Coyne et al. 2006; Hyman et al. 2007; McKay et al. 1996; Project MATCH 1997; Rubin et 

al. 1996; Sun 2007; Zywiak et al. 2006. 

184 Recovery Management and Administrative Considerations 
Relapse prevention education with emphasis on 

postpartum triggers will help women anticipate 

and plan for such triggers. Relapse prevention 

techniques are often taught in groups using 

structured curricula that include strategies for 

maintenance of abstinence and recovery, such 

as identifying high risk situations; learning 

refusal skills that can be practiced with peers 

and staff in advance of “real life” challenges; 

and recognizing triggers that lead to relapse 

thinking, drug craving, and eventual use. 

Although there are multiple new demands placed 

on recovering postpartum women, using the 

tools for relapse prevention in the context of a 

full program of recovery activities is essential 

for continued abstinence. 

During treatment, triggers for drug use should 

be identified and explored with recovering 

women prior to program discharge in concert 

with individualized treatment planning. Many 

of the services and resources used by the 

client prenatally should be continued, if not 

intensified, in the postpartum period. Alumnae 

groups and in-home visitation programs 

have assisted women with relapse prevention 

and family preservation (French et al. 2007; 

Gruber et al. 2001). Drug-specific research on 

postpartum women and relapse has primarily 

examined relapse to smoking after childbirth. 

In one study, correlates of postpartum relapse 

to smoking included high maternal weight 

gain, late or no prenatal care, and stressful 

Figure 8-2 

Women’s Recovery Group: Manual-Based Relapse Prevention 

Group Format: 90-minute sessions 

• Brief check-in 

• Review of past week’s skill practice 

• Presentation on session topic 

• Open discussion of topic and other recovery-related issues 

• Review of session’s “take-home message” and upcoming week’s skill practice 

• Check-out 

Content Areas: 

• The effect of drugs and alcohol on women’s health 

• What are the obstacles to seeking treatment and getting into recovery? 

• Managing mood, anxiety, and eating problems without using substances 

• Violence and abuse: Getting help 

• Women and their partners: The effect on the recovery process 

• Women as caretakers: Can you care for yourself while taking care of others? 

• Women’s use of substances through the life cycle 

• Substance use and women’s reproductive health 

• The issue of disclosure: To tell or not to tell 

• How to manage triggers and high risk situations 

• Using self-help groups to help yourself 

• Can I have fun and not use drugs or alcohol? 

• Coping with stress 

• Achieving balance in your life 

Source: Greenfield et al. 2007b 

Recovery Management and Administrative Considerations 185 
Advice to Clinicians: 

Postpartum Relapse Prevention 

• 

• 

• 

Pregnancy issues must always be fully addressed within a set of comprehensive 

treatment plans, including postpartum relapse prevention. 

Relapse prevention following delivery is especially critical as many clients “quit for the 

baby” and not themselves and thus are susceptible to resume use. 

The postpartum period is saturated with stresses and triggers for relapse, and each 

must be addressed in the client’s relapse prevention plan. 

life events (Carmichael and Ahluwalia 2000). 

Other research suggests that postpartum 

women relapsed to smoking in order to manage 

emotions, stress, and weight, and because they 

did not initially quit for themselves (Bottorff 

et al. 2000; Levine and Marcus 2004). Relapse 

prevention programs for postpartum women 

who smoke can decrease future smoking in some 

of these women (Ratner et al. 2000). 

For many perinatal women who are monitored 

by drug courts, probation, parole, and child 

welfare agencies, the consequences of relapse 

can be devastating in terms of the potential for 

loss of child custody. Perinatal programs, in 

acknowledgment of the importance of parenting 

roles and relationships to women, recognize the 

possibility of relapse and acknowledge that this 

is the time when assistance to the client and her 

child should be intensified, not eliminated. 

Support Systems for 

Women 

Twelve-Step recovery groups have been a 

vital resource for over 50 years, and as time 

has evolved, more women have participated 

in these recovery support groups. Originally, 

the Alcoholics Anonymous (AA) program was 

written by men and primarily for men, and 

the content and language reflected this bias—a 

bias that was steeped in the culture of the time 

period in which it was written. The AA literature 

has since been revised and updated, yet issues 

regarding sensitivity to language and the limited 

focus on cultural and social issues pertinent to 

women’s dependence and recovery remain a 

potential roadblock for some women (Covington 

1994). Nonetheless, 12-Step support groups 

have been the most steadfast peer-facilitated 

program, providing women a viable avenue of 

support in establishing abstinence, in developing 

recovery skills, and in maintaining recovery. 

Most research on the effectiveness of 12-Step 

groups has been conducted with men, but some 

studies have examined gender differences. To 

date, research results refl ect inconsistencies 

regarding differences in attendance and 

abstinence rates between men and women. 

Moos, Moos, and Timko (2006) found that 

women appeared to gain even greater benefi ts 

from AA than men, and women were more likely 

to attend AA and to attend more frequently. 

Compared with men, women showed less 

avoidance coping and greater reduction in 

depression with continued AA participation. 

Another study reported no gender differences 

in 12-Step attendance over a 24-month period, 

including frequency of participation and dropout rates (Hillhouse and Fiorentine 2001). For 

women, availability of support and sponsorship 

appear to be the main ingredients in perceived 

social support in 12-Step recovery groups (Rush 

2002). 

Like men, women have other options for support 

group involvement. Women for Sobriety is the 

only self-help program designed specifi cally for 

women who are alcohol-dependent. Although 

women can benefit from participation in groups 

and from the supporting women-centered 

literature, availability of support groups is 

limited. To date, gender-specifi c outcome 

research on recovery groups outside of 12-Step 

programs is minimal. 

186 Recovery Management and Administrative Considerations 
Administrative 


Considerations
 

Consumer Direction, Participation, 

and Empowerment 

The field of substance abuse treatment has a 

tradition of integrating consumers into service 

delivery as counselors and case managers, 

particularly at the direct service level. However, 

the field is only beginning to learn about and 

apply the enormous benefits received when 

these individuals are integrated into the entire 

fabric of service delivery, from program design 

to implementation and evaluation. For example, 

the SAMHSA-funded Women, Co-Occurring 

Disorders and Violence Study demonstrated a 

priority on including consumers in all aspects of 

study design and implementation throughout the 

5 years of the study. 

Prescott (2001) identifies the important 

contributions made to service systems and 

research when consumers are actively involved. 

When hiring people in recovery as mentors, case 

managers, counselors, and board members, 

characteristics to consider include signifi cant 

time in recovery, ability to handle the expected 

range of tasks, and considerable training 

in issues related to recovery in the specifi c 

treatment areas (Moses et al. 2004). 

Service system benefi ts include: 

• 	Improving quality of services and systems. 

• 	Contributing to systems knowledge. 

• 	Improving customer orientation. 

• 	Positively affecting policy development. 

• 	Adding diversity. 

• 	 Reducing stigma. 

• 	Providing positive role models. 

• 	Promoting increased awareness and 

education among coworkers. 

• 	Providing knowledge about and linkages to 

community and alternative resources. 

• 	Increasing client engagement and retention. 

Research benefi ts include: 

• 	Enhancing research design. 

• 	Promoting engagement of research subjects. 

• 	Broadening interpretations and perspectives 

of research fi ndings. 

• 	Increasing research relevance (Prescott 2001, 

p. 6). 

Active involvement of consumers in all aspects 

of treatment planning signifi cantly contributes 

to both recovery and empowerment, and 

is essential if meaningful, effective services 

for women and children are to be developed 

(Schauer et al. 2007). The consensus panel 

believes consumers should have input into 

program design as well as management and 

research evaluation protocols. In addition, 

training in leadership and advocacy for 

consumers contributes to their feeling of being 

part of a group, effecting changes in their lives 

and communities, learning skills, changing 

others’ perception of their competencies, 

increasing their positive self-images, and 

overcoming stigma. These elements are critical 

components of empowerment (Chamberlin and 

Schene 1997). 

Prescott (2001) lists the benefits to recovering 

women involved in programs: 

• 	 Positive role model. Consumers are positive 

role models when they serve in capacities 

ranging from chief executive officer to support 

staff. Women who volunteer at the treatment 

program or in the community can be positive 

role models for clients new to treatment. 

• 	 Promotion of specifi c skills . As staff members 

in a treatment program, consumers learn 

skills to help themselves communicate with 

community agencies and social service groups 

and learn how organizations change and ideas 

are implemented, thereby gaining a sense of 

control over the environment. 

• 	 Promotion of recovery and well-being. 

Being a part of the treatment milieu, having 

responsibility for an aspect of the program, 

and working with colleagues whose mission 

is to promote wellness can help a woman 

focus her life on maintaining her health and 

recovery. 

• 	Increased sense of hope. The increased 

security of having employment and perhaps 

income helps consumers envision their future 

in a more promising light. 

Recovery Management and Administrative Considerations 187 
• 	 Cultivation of self-effi cacy . As consumers 

acquire the skills they need to make positive 

contributions to the work of the treatment 

program, their belief grows in their abilities to 

handle problems on a broad scale. 

• 	 Decreased stigma. When consumers play 

a role in a treatment program, they give 

evidence that substance abuse is not a 

character flaw or moral defect but an illness 

that can be overcome. Their presence sends 

that message to others and mitigates any 

internalized stigma of consumers. 

Consumer-centered programs incorporate 

the views of women in recovery in all stages of 

program design, management, and evaluation. 

In this way, the quality of services and systems 

integration improves, coworkers become better 

educated about the process of recovery, and the 

stigma of substance abuse is reduced. 

Creating a Healing Environment 

The primary characteristic of a healing 

environment is safety. The environment should 

also be holistic, seamless, and centered on 

a woman’s needs. To promote healing, the 

therapeutic environment must be inviting 

and welcoming, with culturally appropriate 

decorations and pictures. Surroundings should 

be multicultural, highlighting heroines from 

many cultures. A connection to women’s history 

and female heroes plays an important role in 

bolstering women’s self-effi cacy. 

In both residential and outpatient programs, 

the physical layout must provide privacy and 

space where women can be quiet and meditative. 

Private time is needed in their schedules; 

treatment programs can offer an array of services 

that pack a daily schedule, but women need 

time for contemplation and to pursue personal 

interests. Music and recreational activities should 

be available. Space dedicated to child care and 

equipment for children’s activities is essential if 

children are included in the program. 

In women’s treatment programs, sensitivity to 

trauma-related issues is critical to a healing 

environment. A calm atmosphere that respects 

privacy and maximizes client choices promotes 

healing. Staff should be trained to recognize the 

effects of trauma, and women should have a clear 

understanding of the rules and policies of the 

residence. A trauma-informed environment must 

consider: 

• 	 Attention to safety. 

• 	 Attention to boundaries between staff and 

participants, among participants, and between 

participants and visitors (e.g., giving women 

permission to say no to hugging; hugging can 

be a common expression of positive emotion 

for some women, but for those who have been 

traumatized it could represent an undesired 

intrusion into their personal space). 

• 	 Mutuality in staff–staff and staff–client 

relationships. 

• 	 A nonpunitive atmosphere in which confl ict 

is addressed by negotiation to the extent 

possible. 

• 	An organizational structure that allows 

participants access to several layers of staff 

and administrators. 

• 	Encouragement of assertiveness and 

leadership. 

• 	 Self-care. 

Staffi ng 

A woman-centered staff member is an active 

participant in treatment and considers the 

specific needs of women in general and of each 

particular client and how they can be addressed. 

She weighs the realities and complexities of 

women’s lives and their social and gender 

roles with a nonjudgmental attitude. Although 

programs are not always able to hire a woman 

for each staff position, a program still can 

adhere to a woman-centered philosophy. A 

key rationale for having female staff work with 

female clients is role modeling; people watch 

more than they listen. A woman-run program 

shows clients how women can exercise power 

effectively. Women need to be seen in leadership 

roles in the program. 

This goal does not, however, exclude men as 

treatment providers for female clients; men 

who are respectful of women’s experiences 

can help women. They must have a womancentered perspective and be knowledgeable 

about women’s issues, particularly trauma 

188 Recovery Management and Administrative Considerations 
and domestic violence. In residential programs 

or other programs with children’s services, 

male staff members can play a valuable role 

by being healthy male role models for women 

and their children. Women report that working 

with a male counselor who is compassionate 

and respectful can be a healing experience, 

particularly if they endured negative 

relationships with men. Ideally, a woman should 

have the option to choose either a man or a 

woman as her primary counselor. 

Men can serve in a variety of roles in 

nonresidential programs, including case manager, 

housing coordinator, couples’ or children’s 

counselor, and general equivalency diploma 

teacher. They can provide a male point of view 

about parenting and assist in exploring the 

attitudes and behavior of the clients’ partners. 

Training 

Treatment providers and staff members at 

all entry points in systems that serve women 

need to be able to screen, triage, and refer for 

substance abuse treatment using an approach 

that supports and encourages women to receive 

treatment. Because of a lack of knowledge 

about substance use generally and about women 

particularly, as well as the tremendous stigma 

attached to women who abuse substances, it 

is important that all staff training include a 

process that identifies, acknowledges, and brings 

to awareness the biases, judgments, and anger 

toward women who use and abuse substances. 

The pervasiveness of substance use and abuse 

and the negative effect it has on the lives of 

so many people make it difficult to remain 

objective as a helping professional. If women 

are to be identified and referred when in need 

of treatment for their substance use, those in 

a position to help must be able to interact in a 

manner that assists and causes no harm. 

Training for point-of-entry 

providers 

Point-of-entry providers see women with a 

variety of complaints and have the potential 

to identify and refer women for assessment 

and treatment. These point-of-entry providers 

include those in healthcare, domestic violence, 

social service, child protection, mental health 

systems; schools and daycare centers; the 

criminal justice system; TANF (Temporary 

Assistance for Needy Families) workers, 

judges, and clergy. The consensus panel 

recommends that because these providers 

are in the position to identify women in need 

of substance abuse treatment, a minimum 

standard of cross-training among systems and 

within interdisciplinary groups is needed. With 

a heightened focus on cultural and linguistic 

competency, along with substance abuse 

education, training can help practitioners avoid 

creating barriers to treatment when clients are 

from cultures, ethnicities, or sexual orientations 

different from their own (Goode et al. 2006). 

Figure 8-3 defines the attitudes, skills, and 

knowledge that should be the goals for training 

an audience of point-of-entry staff. 

Training for substance abuse 

treatment counselors 

Although it is widely assumed that clinical 

staff members who provide substance abuse 

treatment are prepared to serve both men and 

women, the training received by clinicians does 

not always specifically include women-centered 

treatment. The consensus panel believes 

that training for clinicians should include 

information on the psychological growth and 

development of women, cultural competence, 

sexual orientation and gender identity issues, 

the role of relationships in women’s development 

of a sense of self, the importance of children in 

the treatment process, children’s importance in 

the lives of mothers, and the sense of adequacy 

in parenting that is vital to self-esteem. Training 

should include information on the etiology of 

use and abuse of substances in women and the 

physiological effects that are unique to women. 

Counselors also need to be able to disseminate 

accurate information about the bodily changes 

and potential effects of substance use on both a 

pregnant woman and her fetus. 

In addition, social roles and status in society 

strongly influence the patterns, consequences, 

and context of use, as well as the treatment 

Recovery Management and Administrative Considerations 189 
Figure 8-3 

Goals and Training Guidelines for Point-of-Entry Staff 

(Non–Substance-Abuse Treatment Providers) 

Goals Guidelines 

Attitudes • To be nonjudgmental, supportive, and respectful 

• To be culturally responsive and appropriate 

Skills • To actively listen and express concern 

• To treat all women with respect and dignity 

• To engage women in nonthreatening discussions 

• To routinely screen for alcohol and substance use and abuse (e.g., 

complete a behavioral checklist, identify behavioral signs) 

• To recognize signs of intoxication and symptoms of mental disorders 

• To facilitate appropriate referrals for women who abuse substances 

Knowledge • To understand women’s lives in sociocultural, psychological, 

economic, and political contexts 

• To learn about the etiology, symptoms, consequences, and course of 

substance use disorders among women 

• To know the available treatment and support resources for women 

who abuse substances and how to make a referral 

• To continue to learn drug language and culture 

• To understand the diverse experiences of women from different 

cultural groups, sexual orientations, and gender identities 

experience. Some clients need to feel empowered 

to assume new roles, make decisions and a new 

life, and remain substance free. Treatment staff 

can help clients find acceptance, understand 

their conflicts, and reach comfortable roles. 

Figure 8-4 defines the attitudes, skills, and 

knowledge that training should instill in 

an audience of substance abuse treatment 

counselors. 

Supervision 

The consensus panel recommends that staff 

supervision be built into an agency’s procedures 

on two levels: administrative supervision 

(timesheets, policies, etc.) and clinical 

supervision. Clinical supervision provides a 

method to address countertransference issues 

or other problems when a staff member’s 

values, attitudes, and/or expectations might 

interfere with the therapeutic process. 

Clinical supervisors can help counselors foster 

therapeutic alliances and help providers 

learn to use the therapeutic relationship to 

model and foster mutuality, respect, and 

connection for women (Finkelstein 1996; 

Finkelstein et al. 1997). Literature from crosscultural psychology and social work shows 

that therapeutic relationships with those who 

have substance use problems are stronger and 

more effective if the counselor understands 

the client’s historical, cultural, and economic 

background (Pedersen et al. 1989; Sue and 

Sue 2003). Research in psychology shows that 

counselors’ gender and ethnicity can affect the 

diagnoses they assign (Loring and Powell 1988). 

This speaks to the need for ongoing clinical 

190 Recovery Management and Administrative Considerations 
Figure 8-4 

Goals and Training Guidelines for Substance Abuse Treatment 

Counselors 

Goals Guidelines 

Attitudes • To main tain a nonjudgmental, supportive, and respectful manner 

• To understand the diverse experience of women from different cultural 

groups, abilities, sexual orientations, and gender identities (e.g., be aware of 

attitudes toward race, sex, and disability) 

• To be committed to women’s issues 

• To uphold a sense of hope 

• To demonstrate unconditional acceptance of and positive regard for the client 

Skills • To engage women with empathy, warmth, and sincerity 

• To develop a treatment alliance with female clients that is mutual and 

collaborative, individualized, and continually negotiated 

• To have clear professional boundaries (neither distant nor abandoning) and 

maintain confi dentiality 

• To remain consistent in caring and availability and possess the ability to set 

limits in a calm and supportive manner 

• To conduct assessments that are thorough and trauma informed 

• To develop individually focused and outcome-oriented treatment plans 

• To work with multidisciplinary teams 

• To perform crisis intervention 

• To apply trauma coping skills 

• To tolerate one’s own distress in hearing trauma information 

• To deliver client-led treatment (e.g., help the client learn how to manage her 

distress without shutting down or becoming overwhelmed—a central focus of 

treatment) 

• To maintain and ensure self-care 

• To support clients’ cultural and racial identities and sexual orientations 

• To ask for and participate in supervision, in part to explore personal biases in 

ongoing processes, and to be invested in ongoing training 

• To be a visible advocate for women who use/abuse substances for stigma 

reduction and for treatment (within treatment teams, the community, and the 

system) 

• To be an appropriate role model for women, including on the topic of 

parenting 

• To develop professional, respectful, mutually supportive, and collaborative 

relationships with coworkers 

Recovery Management and Administrative Considerations 191 
Figure 8-4 

Goals and Training Guidelines for Substance Abuse Treatment 

Counselors (continued) 

Knowledge • 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

To be culturally informed and knowledgeable 

To be trauma informed, including awareness of the prevalence and impact of 

trauma on women’s lives 

To understand the psychological growth and development of women 

To recognize the centrality of relationships for women, particularly parenting 

and social roles and the socialization process 

To be knowledgeable about the physiology of women as it relates to substance 

use and abuse 

To understand the etiology of substance abuse in women 

To be familiar with the co-occurring disorders that commonly occur in women 

To understand the context of abuse and patterns of use for women 

To identify the consequences of substance abuse (e.g., legal, general health, 

infectious diseases, family and relationships, psychological) 

To understand the treatment and recovery experience of women 

To identify family dynamics (e.g., family of origin, parenting, child 

development) 

To be familiar with a woman’s process of recovery 

To be knowledgeable about relapse prevention for women; relapse triggers 

such as family reunification; recovery resources; maintaining a safe place for 

the client; and loss, grief, and mourning 

To understand issues related to sexuality, sexual orientation, and gender 

identity for women and their relationship to substance abuse 

To know confidentiality rules and guidelines 

supervision of counselors and to the need for 

training individuals to be effective supervisors 

(Cramer 2002). Supervisors also can support 

staff members who are in recovery and working 

as volunteers or mentors. 

Clinical supervision for trauma 

The management of the powerful effect 

associated with trauma presents challenges for 

counselors. As a result of their intense daily 

contact with trauma survivors, counselors are 

vulnerable to many symptoms and conditions 

including: 

Vicarious traumatization. The experiences of 

trauma frequently are overwhelming for clients. 

As counselors listen to the life experiences of 

their clients, they too are at risk of becoming 

overwhelmed. Counselors can develop symptoms 

of depression, such as sleep disturbance, loss of 

appetite, or loss of pleasure in usually enjoyable 

activities. Programs can take various steps to 

lessen the effect of vicarious traumatization: 

• 	Training. Staff training on trauma issues 

(including vicarious traumatization) and on 

the connections between trauma, substance 

abuse, and mental illness, help staff address 

trauma experiences. 

• 	 Supervision. Regular clinical supervision 

helps counselors unburden themselves. The 

sooner a counselor’s distress is addressed, 

the easier it is to manage. Understanding the 

counselor’s emotional vulnerabilities when 

she works with women who were traumatized 

is essential to providing effective treatment 

and allowing staff to work well, safely, and 

consistently. 

• 	 Debriefi ng . Managers and supervisors need to 

ensure that counselors debrief after hearing 

painful and intense histories from their 

clients and to watch for signs of counselors 

becoming overwhelmed. 

192 Recovery Management and Administrative Considerations 
• Self-care. Agency support should include 

awareness and education about signs of 

burnout, breaks from work, vacations, and 

varied schedules (i.e., with periods of less 

exposure to trauma histories). 

• 	 Employee services. Through peer support 

groups, an agency can acknowledge that 

vicarious traumatization is taking place and 

that its employees’ ability to do their jobs 

well is important. 

• 	 Staff appreciation. Program managers 

and supervisors should be aware that staff 

members perform an important function as 

role models; they need to let staff members 

know they are valued. Counselors need to 

be examples of assertive, appropriate, highfunctioning adults. 

Supervision for counselors can be understood 

in a rock-climbing metaphor. The client has 

survived a terrible experience; it is as if she were 

on a high and windy ledge, still alive, but unable 

to find her way back to safety. To help her, the 

counselor must go out on the ledge; calling to 

her from safe ground will not do. To manage the 

task, the counselor must be tied to a supervisor, 

much as a rock climber is tied to another 

climber, to keep from falling (Cramer 2002). 

Strategies for Organizational 

Change 

A program seeking to become woman-centered 

cannot limit the transformation process to 

simply adopting superficial elements of the 

treatment culture (Markoff et al. 2005), such 

as creating a female-only program without 

changing program structure, integrating 

services, or building collaborative relationships 

across community agencies. Rather, it must 

use numerous strategies and endorse a change 

model to ensure organizational change is deep, 

pervasive, and across systems. The consensus 

panel recommends the following: 

• 	 Training and education . Staff members 

need help in identifying their biases and 

assumptions. Such training does not have to 

be intensive or expensive to be effective. For 

example, agencies can trade speakers. 

• Policies and procedures. It is critical that 


programs have clear policies and procedures, 

and that women are informed of these 

policies and procedures at the beginning 

of their treatment. Programs must be 

consistent in how they implement policies 

and procedures. This is important from both 

a program management perspective and a 

clinical treatment perspective. Having clear, 

reasonable standards that are implemented 

uniformly creates a safe and predictable 

environment for clients. 

Drug and alcohol testing and searches for 

contraband must be done respectfully, 

letting the client know it is part of 

treatment and seeking her cooperation. 

It is necessary to spend time building a 

relationship with the client and to give her 

an opportunity to admit to a relapse or to 

remove items that are not permitted in a 

residential community. 

Staff must reinforce policies and rules 

uniformly and without preferential 

treatment. Fairness and justice are critical 

for women in treatment, and they must be 

modeled by the staff. 

Rules and punitive restrictions must 

be germane to treatment. For example, 

some programs do not allow women to 

talk to their children for the fi rst 30 

days of treatment. Such a blanket rule 

is inappropriate for children and shows 

disrespect for the importance of the 

mother–child relationship. Arbitrary rules 

are disempowering for women and not 

part of a collaborative relationship. The 

treatment milieu is a model for parent– 

child relationships, in which the use of 

arbitrary rules is discouraged. Following 

rules and procedures should not result 

in acts that retraumatize women. For 

example, it could be frightening for some 

women to have counselors check rooms at 

night while the women are sleeping. 

• 	 Top-down support for change . Advocacy 

for the program’s philosophy of treatment is 

essential. It must be top down and explicit. 

• 	 Hiring, retention, and promotion. Programs 

must reflect women’s needs, possibly 

Recovery Management and Administrative Considerations 193 
including onsite daycare for staff, sickchild care, support (both fi nancial and 

technical) for staff to become certifi ed as 

addiction counselors, onsite training, and a 

good health benefits package. The programs 

should consider ways in which male staff 

members can contribute to woman-centered 

programming. Staff members are more likely 

to support staffing policies and procedures 

when they are involved in their development. 

• 	Consumer input. The development of 

consumer advisory boards allows clients to 

share their input and lets them know their 

opinions are valued and respected. 

• 	 Relationships. Positive relationships are of 

immeasurable value to women. How staff 

members relate to one another is part of the 

treatment milieu. Administrators need to 

model respectful relationships with clients 

and staff and incorporate support services 

for staff issues, such as mediation for 

staff conflicts and peer support groups for 

handling job stress. 

• 	The environment is a message. Women 

recover best in a homelike atmosphere that 

is warm and welcoming for them and their 

children. The program environment needs 

to reflect the diverse cultures of the staff 

and clients; all groups can participate in 

designing, arranging, and furnishing the 

facility. 

• 	 Adopt a change model. Administrators and 

supervisors need to develop a change plan to 

maintain a steadfast course in adopting new 

policies and procedures and in integrating 

services. Anticipation of roadblocks, methods 

for creating buy-in with staff, and strategies 

for building interagency relationships are a 

few issues that need consideration. Relevant 

resources to help support and guide change 

include the Relational Systems Change Model 

(Markoff et al. 2005a) and The Change 

Book: A Blueprint of Technology Transfer 

(Addiction Technology Transfer Center 

[ATTC] 2004). 

• 	Collaborative relationships. Establishing 

a collaborative relationship with the client 

provides the woman with an experience 

of mutuality and shared power in a 

relationship, which in itself is part of healing. 

At all times, staff members should work 

respectfully and in partnership with the 

client, and should: 

Set a positive tone for the treatment 

relationship. Counselors get a good 

start by showing respect for the clients’ 

personal needs and comfort. For example, 

one treatment agency keeps a book that 

highlights the stories of women who have 

successfully completed treatment. Another 

offers clients food and drink. During a 

long client-assessment session, a counselor 

can offer a client a break instead of 

waiting for the client to ask for one. If 

possible, during the break the counselor 

should interact with the client so that 

she does not feel alone. However, if she 

requests it, the client should have private 

time. 

Treat substance abuse as a health issue, 

not a moral one. A client who feels judged 

is more likely to leave treatment. Let 

clients know how they can be involved in 

their treatment, explain the process to 

them, explain the roles of the treatment 

staff members, and explain when clients 

will make decisions with staff about their 

treatment (i.e., during treatment planning, 

reassessments, discharge). 

Allow time to hear the client’s stories. Too 

often, a client’s low self-esteem is made 

even lower by cues that there is not enough 

time to listen to her. 

Do what is necessary to ensure that 

the client understands the assessment 

and treatment processes. For a client 

with cognitive impairment, this can 

involve breaking down the process into 

short sessions, repeating or explaining 

questions, proceeding more slowly, using 

less abstract language, or presenting 

information in an alternative format. 

Seek feedback from the client on how 

her treatment plan is working. Inquire 

where she is in relation to her goals for 

treatment, her life, and her feelings about 

her progress. Implement formal strategies 

to obtain client feedback on a regular 

basis instead of gathering this data at the 

termination of treatment. 

194 Recovery Management and Administrative Considerations 
When addressing noncompliance with 

clients, involve them in identifying the 

problem and its solution. Use policies that 

are educational rather than punitive. For 

example, encourage clients to examine the 

behaviors they need to change, how staff 

can help them in this process, an agreeable 

timeframe for doing so, and so on. 

State substance abuse treatment 

standards for women 

To provide general guidance in establishing and 

providing services for women, administrators 

and clinical staff benefit from reviewing 

available State standards or protocols for 

women, pregnant women, and women and 

children programs for substance abuse 

treatment (for review, see CSAT 2007). Figure 

8-5 provides examples of State standards of 

gender-specific treatment across the continuum 

of care. 

Figure 8-5 

State Standard Examples of Gender-Specifi c Treatment 

Gender-Specifi c 

Women Services 

State Standard Examples 

Treatment • A relational or cultural approach that focuses on the relevance and

Approach centrality of relationships for women must be a vital ingredient in 

treatment 

• Selected treatment approaches shall be grounded in evidence-based or

best practices for women 

Screening/ • Screening and assessments shall involve the use of tools, including the

Assessment Addiction Severity Index and Stages of Change/Readiness Assessment 

• Assessments shall evaluate barriers to treatment and related services

• Assessment and documentation of a client’s need for prenatal care shall 

be included in the assessment process 

• History and assessment of interpersonal violence shall be evaluated

• Sensitivity to retraumatization must be taken into consideration in the

assessment process 

• Assessment shall be a collaborative process across agencies

Treatment Planning • Planning shall include participation of significant others and other 

agencies; i.e., child welfare, correction, and other social service 

agencies 

Treatment Programs • Emotional and physical safety of women shall take precedence over all

other considerations in the delivery of services 

• Women-only therapeutic environments shall be made available 

• Treatment shall include psychoeducation on the impact of gender on 

development and functioning in society 

• Treatment must be strength-based 

Recovery Management and Administrative Considerations 195 
Figure 8-5 

State Standard Examples of Gender-Specific Treatment (continued) 

Treatment Services • Services must provide prenatal and childcare services

• Treatment shall include smoking cessation strategies and programs 

• Services shall include child safety, parenting, and nutrition services 

• Wrap-around and integrated interagency and intra-agency services 

must be an integral part of treatment delivery services 

Trauma-Informed 

and Integrated 

Trauma Services 

• Treatment considerations shall incorporate an understanding of the 

way symptoms of trauma affect treatment, progress in treatment, and 

the relationship among counselor, program, and client 

Co-Occurring 

Disorders 

• Treatment must include symptom management strategies 

• Services for mental health and substance abuse treatment shall be

integrated and coordinated 

Staffing • The program must provide gender-specifi c staff 

• Treatment services shall involve a majority of women as staff members 

Support Systems • The program shall make use of peer supports

• Referrals shall be made to female-dominated support groups where

available 

Staff Training • Formal staff training in women’s treatment needs must include family 

counseling, trauma-informed services, prenatal education, etc. 

Program Evaluation • Program must measure short- and long-term impact of interventions,

including educational attainment, employment, housing, parenting and 

reunification with children, and physical and mental health 

Source: Adapted from Connecticut Treatment Guidelines 2007; Colorado Alcohol and Drug Abuse Division Substance 

Use Disorder Treatment Rules 2006; Oklahoma Department of Mental Health and Substance Abuse Services Standards 

and Criteria for Alcohol and Drug Treatment Programs 2008; and Oregon Department of Human Services Standards 

for Outpatient and Residential Alcohol and Drug Treatment Programs 2008. 

Guidance to States: Treatment Standards for Women with Substance 

Use Disorders 

This document serves as a comprehensive guide to assist States in creating their own treatment 

standards for women with substance use disorders. It provides a summary of existing State 

standards and incorporates other relevant resources pertinent to women’s treatment needs 

across multiple service systems. Specific concerns for special populations are addressed, such as 

pregnant women, women with children, and women involved in the criminal justice system (The 

National Association of State Alcohol and Drug Abuse Directors 2008; see http://www.nasadad. 

org/resource.php?base_id=1482). 

196 Recovery Management and Administrative Considerations 
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Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1993. 

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Bisexual, And Transgender Populations. 

Revised 2000 ed. Rockville, MD: Center for 

Substance Abuse Prevention, 2000. 

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Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1993a. 

Center for Substance Abuse Treatment. Pregnant, Substance-Using Women. Treatment 

Improvement Protocol (TIP) Series 2. HHS 

Publication No. (SMA) 93-1998. Rockville, 

MD: Substance Abuse and Mental Health 

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95-3060. Rockville, MD: Substance Abuse 

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1993c. 

Center for Substance Abuse Treatment. Practical Approaches in the Treatment of Women 

Who Abuse Alcohol and Other Drugs. HHS 

Publication No. (SMA) 94-3006. Washington, DC: U.S. Government Printing Offi ce, 

1994a. 

Center for Substance Abuse Treatment. Simple 

Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious 

Diseases. Treatment Improvement Protocol 

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94-2094. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1994b. 

Center for Substance Abuse Treatment. Alcohol 

and Other Drug Screening of Hospitalized 

Trauma Patients. Treatment Improvement 

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No. (SMA) 95-3041. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 1995a. 

Center for Substance Abuse Treatment. Combining Alcohol and Other Drug Treatment 

with Diversion for Juveniles in the Justice 

System. Treatment Improvement Protocol 

(TIP) Series 21. HHS Publication No. (SMA) 

95-3051. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1995b. 

Center for Substance Abuse Treatment. Developing State Outcomes Monitoring Systems 

for Alcohol and Other Drug Abuse Treatment. Treatment Improvement Protocol 

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95-3031. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1995c. 

Center for Substance Abuse Treatment. The 

Role and Current Status of Patient Placement Criteria in the Treatment of Substance 

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(SMA) 95-3021. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 1995d. 

Center for Substance Abuse Treatment. The 

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Issues for Alcohol and Other Drug Abuse 

Treatment Providers. Treatment Improvement Protocol (TIP) Series 18. HHS Publication No. (SMA) 95-3047. Rockville, MD: 

Substance Abuse and Mental Health Services 

Administration, 1995e. 

Center for Substance Abuse Treatment. Treatment Drug Courts: Integrating Substance 

Abuse Treatment With Legal Case Processing. Treatment Improvement Protocol (TIP) 

Series 23. HHS Publication No. (SMA) 

96-3113. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1996. 

Center for Substance Abuse Treatment. A Guide 

to Substance Abuse Services for Primary 

Care Clinicians. Treatment Improvement 

Protocol (TIP) Series 24. HHS Publication 

No. (SMA) 97-3139. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 1997a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment and Domestic 

Violence. Treatment Improvement Protocol 

(TIP) Series 25. HHS Publication No. (SMA) 

97-3163. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1997b. 

Center for Substance Abuse Treatment. Supplementary Administration Manual For The 

Expanded Female Version Of The Addiction 

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208 Appendix A: Bibliography 
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98-3245. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1998b. 

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Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series 

26. HHS Publication No. (SMA) 98-3179. 

Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1998d. 

Center for Substance Abuse Treatment. Substance Use Disorder Treatment for People 

With Physical and Cognitive Disabilities. 

Treatment Improvement Protocol (TIP) 

Series 29. HHS Publication No. (SMA) 

98-3249. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1998e. 

Center for Substance Abuse Treatment. Brief 

Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34. HHS Publication No. 

(SMA) 99-3353. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 1999a. 

Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance 

Abuse Treatment. Treatment Improvement 

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No. (SMA) 99-3354. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 1999b. 

Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance 

Use Disorders. Treatment Improvement Protocol (TIP) Series 31. HHS Publication No. 

(SMA) 99-3282. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 1999c. 

Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Use 

Disorders. Treatment Improvement Protocol 

(TIP) Series 32. HHS Publication No. (SMA) 

99-3283. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

1999d. 

Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Treatment 

Improvement Protocol (TIP) Series 33. HHS 

Publication No. (SMA) 99-3296. Rockville, 

MD: Substance Abuse and Mental Health 

Services Administration, 1999e. 

Center for Substance Abuse Treatment. Integrating Substance Abuse Treatment and 

Vocational Services. Treatment Improvement 

Protocol (TIP) Series 38. HHS Publication 

No. (SMA) 00-3470. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2000a. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With 

Child Abuse and Neglect Issues. Treatment 

Improvement Protocol (TIP) Series 36. HHS 

Publication No. (SMA) 00-3357. Rockville, 

MD: Substance Abuse and Mental Health 

Services Administration, 2000b. 

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With 

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00-3459. Rockville, MD: Substance Abuse 

and Mental Health Services Administration, 

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Their Stories: Reflections Of The 11 Original 

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MD: Substance Abuse and Mental Health 

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MD: U.S. Department of Health and Human Services, Substance Abuse and Mental 

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272 Appendix A: Bibliography 
Appendix B: CSAT’s 

Comprehensive 

Substance Abuse 

Treatment Model for 

Women and Their 

Children 

By the CSAT Women, Youth and Families Task Force 

Background 

In the early 1990s, Congress appropriated funds to the newly 

created Substance Abuse and Mental Health Services Administration 

(SAMHSA), Center for Substance Abuse Treatment (CSAT) to support 

long-term residential substance abuse treatment programs for women 

with children. Two separate demonstration programs were funded, 

including the Residential Women and Children’s (RWC) program, and 

the Pregnant and Postpartum Women and Children’s (PPW) program. 

Based in part on the experiences of the RWC and PPW programs, 

CSAT published a “Comprehensive Treatment Model for Alcohol and 

Other Drug-Abusing Women and Their Children” in order to help 

substance abuse treatment providers develop program services to meet 

the comprehensive needs of the women and children served by these and 

other programs. The model was included in a 1994 CSAT publication, 

Practical Approaches in the Treatment of Women Who Abuse Alcohol 

and Other Drugs. 

This model recognized that there was an important difference between 

“treatment that addresses alcohol and other drug abuse only” and 

“treatment that addresses the full range of women’s needs.” As stated in 

the model 

Treatment that addresses the full range of a woman’s needs 

is associated with increasing abstinence and improvement in 

other measures of recovery, including parenting skills and 

overall emotional health. Treatment that addresses alcohol 

and other drug abuse only may well fail and contribute to a 

higher potential for relapse (CSAT 1994f). 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 273 
CSAT’s model remains an important 

contribution toward describing an approach 

to working with women that recognizes the 

importance of gender in the design and delivery 

of services for women and their families. 

Since 1994, the field has gained additional 

insights about critical needs of women and 

children and the role that partners and fathers 

play regarding these needs. The knowledge 

gained in the past decade should drive the 

delivery of services to women. These insights 

include the following: 

• 	Psychological differences between men 

and women and, in particular, the 

heightened importance that women place on 

relationships have a great impact on both 

women’s gateways into addiction and relapse 

once in recovery. A woman’s focus within 

relationships is often to serve as “caretaker,” 

a role that can result in a woman not 

attending to her own needs. Positive, 

therapeutic relationships, on the other hand, 

can also act as powerful tools for supporting 

a woman’s recovery. 

• 	Women self-medicate with addictive 

substances to mask pain associated with 

underlying trauma, including past and 

ongoing domestic violence as well as 

childhood abuse and neglect. The high 

prevalence of a history of trauma among 

women receiving substance abuse treatment 

heightens the need for substance abuse 

treatment to recognize the critical impact of 

trauma on the woman’s recovery. 

• 	 The prevalence of co-occurring mental health 

disorders among women receiving substance 

abuse treatment has also come to light over 

the past decade and raises the need for 

providing coordinated services to address both 

substance use and mental health disorders. 

• 	Women appear to be significantly affected by 

the service systems they depend on, including 

welfare agencies and child welfare agencies, 

which tend to operate independently, with 

different timetables and perspectives on the 

purposes of recovery. 

• 	A new understanding has arisen about the 

benefits of women’s economic self-suffi ciency 

in the process of long-term recovery. This 

is partly a result of the pressures of society, 

exemplified by welfare reform and data 

indicating that gainful employment can be a 

protective influence for preventing relapse. 

• 	The field has also come to appreciate that 

children of women in treatment have many 

of their own needs that cannot simply be 

addressed by the provision of child care 

and residential living space. These needs 

are addressed when children are provided 

services directly, as well as when the needs of 

their parents are met. 

• 	Both mothers and fathers should receive the 

education and support necessary to prepare 

them for the responsibility of parenthood, 

understanding that the roles fathers play in 

families are diverse and related to cultural 

and community norms, the health and wellbeing of the father, and the viability of the 

parents’ relationship to one another. 

• 	Changes in family composition play a role in 

supporting women and recovery. In 1960, 

fewer than 10 million children did not live 

with their fathers (U.S. Bureau of Labor 

Statistics n.d.). By the turn of the century, 

the number had risen to nearly 25 million. 

More than one-third of these children will not 

see their fathers at all during the course of a 

year. Studies show that children who grow up 

without responsible fathers are signifi cantly 

more likely to experience poverty, perform 

poorly in school, engage in criminal 

activity, and abuse drugs and alcohol (U.S. 

Department of Health and Human Services 

2000a). 

This update to the model considers the needs of 

women, their children, and their families in the 

context of their community and culture. 

An Evolving Paradigm 

As was the case with the earlier version, the 

purpose of this model is to 

Foster the development of state-of-theart recovery for women with alcohol and 

other drug dependence and to foster the 

274 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
healthy development of the children of 

substance abusing women. The model is 

a guide that can be adapted by communities and used to build comprehensive 

programs over time (CSAT 1994f, p. 

267). 

CSAT’s Comprehensive Treatment Model 

continues to reinforce that confi dentiality and 

informed consent, as well as the establishment 

of universal precautions against the spread 

of sexually transmitted and other infectious 

diseases, are essential throughout all aspects of 

treatment (CSAT 1994e, 2000d). 

In addition to incorporating the new knowledge 

about the common histories and service needs of 

women and their children, this model goes a step 

further by delineating the relational elements of 

the service continuum that have an impact on 

treatment for women. These elements shown in 

Figure B-1 below and are categorized as 

• 	Clinical treatment services: those services 

necessary to address the medical and 

biopsychosocial issues of addiction 

• 	Clinical support services: services that assist 

clients in their recovery 

• 	Community support services: those services 

and community resources outside of 

treatment but within a community that serve 

as an underpinning or support system for the 

recovering individual 

In parallel, the model also describes clinical 

treatment and clinical support services for 

children of women in treatment. 

Research has established that there are many 

paths to recovery from alcohol and drug 

problems. Some women resolve their alcohol 

and drug problems with individual and family 

supports and without any outside intervention. 

Others recover with support from self-help 

groups such as Alcoholics Anonymous and/ 

or the faith community. Still others have 

found recovery through formal treatment 

interventions. A variety of factors can infl uence 

which of these paths is successful, including 

the severity of the problems and the support 

systems available to women with substance use 

disorders. 

To achieve the best outcomes at the lowest cost, 

SAMHSA encourages the establishment of a 

comprehensive continuum of recovery. The full 

complement of these services is appropriate 

for many women who meet the Diagnostic 

and Statistical Manual of Mental Disorders, 

Fourth Edition (DSM-IV) diagnostic criteria 

for substance use disorders. However, not 

all services and/or interventions are needed 

by every woman in treatment or recovery for 

substance dependence, and those who meet the 

diagnostic criteria for substance abuse may 

require a less comprehensive range of services 

than those who are substance dependent. 

Similarly, women with a range of family, social, 

and economic supports may not require a full 

complement of services while those who have 

fewer naturally occurring supports may require 

more services from the formal health, social, 

and economic supportive systems. 

The array of services described below does not 

need to be provided by a single entity, but in 

most instances will be provided by a consortium 

of addiction treatment, health, and human 

service providers. The continuum is not specifi c 

to philosophies of treatment and recovery, 

modality, or setting. It is a generic framework 

within which providers can conceptualize service 

arrays, service capabilities, and appropriate 

managerial and administrative processes. 

Methods of implementing each service, the 

manner and setting in which different services 

are delivered, and other ingredients of the 

model should be based upon an assessment and 

patient placement determination that considers 

(1) the needs of the individual, and (2) the extent 

to which the continuum of services is available in 

the community. 

To better understand the model, it is helpful 

to view services as a series of interwoven and 

interdependent circles of care that are necessary 

to support the recovery process for women. 

In the Navajo Nation, the woven basket 

is actually a series of concentric rings, 

one lying within the other, expanding 

outward and upward until the entire 

basket is shaped. By itself, one ring can 

hold nothing and bear no load. When 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 275 
Figure B-1 

Interrelated Elements in the Comprehensive Treatment Model 

bound together, the circles join, gain 

strength, and what before could hold 

nothing now holds stones for building 

nations and water for building bodies. 

The concept of interdependence is critical 

to understanding the model. Each circle 

requires the existence of the other two and yet 

they are depicted as dotted lines to illustrate 

their permeability. The three circles together 

comprise comprehensive treatment, and any 

provider seeking to emulate the model must 

also ensure that there is an interdependent 

relationship among the three systems. 

Borrowing again from the basket metaphor, 

the circles are also three-dimensional as a 

basket must be and, as such, have binders 

that interweave and hold the circles together. 

Likewise, in treatment, there are activities 

that weave through each circle, helping to bind 

the service continuum together. Housing is a 

good example. Some people with substance 

use disorders are functionally homeless and, 

thus, the issue of housing permeates clinical 

treatment, clinical support, and community 

support. 

A final and critical aspect of how the circles 

are interrelated requires the inclusion of two 

276 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
concepts that provide the foundational support 

to the network of comprehensive care: cultural 

competence and gender competence. These 

concepts are graphically displayed as the 

handles to pick up and use the basket. For a 

system of care to be comprehensive in nature, 

it must have cultural and gender competence at 

all levels of treatment and support. The terms 

cultural competence and gender competence 

mean more than knowledge about culture or 

gender. The terms require practitioners to be 

knowledgeable, understanding, and sensitive 

to the milieu from which the woman comes 

regarding the issues and concerns she may bring 

to treatment. These include the socioeconomic 

context of her background; her sexual identity; 

the sources of potential anger, hurt, and fear; 

and disconnection from family, friends, and 

community. Both cultural competence and 

gender competence require recognition of the 

biases that may exist within the programs and 

practitioner that will impact treatment and 

relationships with clients. 

Clinical Treatment Services
 

As shown in Figure B-2, the fabric of the basket 

is interwoven with a range of clinical treatment 

services. These services include the following 

elements: outreach and engagement, screening, 

detoxification, crisis intervention, assessment, 

treatment planning, case management, 

substance abuse counseling and education, 

Figure B-2 

Elements of Clinical Treatment Services 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 277 
trauma-informed and trauma-specifi c services 

and psychoeducational therapies, medical care 

(including treatment for infectious diseases, 

women’s health, and health education), 

pharmacotherapies, mental health services, 

drug monitoring, and continuing care (these 

services are defined and further explained in the 

last section of this appendix). While arguments 

could be made to support the addition of other 

core services to this continuum, experience has 

shown that these elements of service are typical 

of those that are under the core umbrella of 

treatment programs. 

For most women in treatment, particularly those 

burdened with issues such as intergenerational 

poverty, violence, and homelessness, timelimited clinical treatment services alone will 

not likely result in sustained recovery. Women 

with multiple needs will need support from 

other systems, designated clinical support, 

and community support to achieve success in 

recovery. 

Addiction affects women’s connections and 

relationships, causing them to leave or abandon 

many of the relational systems upon which they 

formerly depended—family, friends, and roots 

in the community. Thus, for a woman to succeed 

in treatment, deliberate steps must connect her 

with the support structures that allow her to 

reverse the isolation and fragmentation often 

synonymous with addiction and reconnect 

with these important relationships. While 

some of that occurs within the context of 

clinical treatment itself, other aspects of the 

reconnection process occur as a result of clinical 

support and community support services. 

Clinical Support Services 

Within this circle is an array of services that, 

by themselves, are not necessarily part of the 

treatment modality but, like ball bearings to 

machinery, make the treatment modality work. 

These support services (shown in Figure B-3) 

include primary healthcare services, life skills, 

parenting and child development education, 

family programs, educational remediation 

and support, employment readiness services, 

linkages with the legal and child welfare systems, 

housing support, advocacy, and recovery 

support services. Elsewhere in this appendix, 

similar circles are identified that relate to the 

special needs of children. While introduced 

separately, they are inextricably intertwined 

with those of the parenting woman. 

Clinical support services are not ancillary 

services, they are a critical part of treatment 

designed to prevent relapse. This model suggests 

that these services are not enhancements of 

treatment but, rather, critical elements of 

treatment designed to promote overall well-being 

and prevent relapse. 

Community Support 

Services 

Community support services are those that 

must be available in the community to ensure 

long-term recovery. These services, as shown 

in Figure B-4, include recovery management, 

recovery community support services, housing 

services, family strengthening, child care, 

transportation, Temporary Assistance for Needy 

Families (TANF) linkages, employer support 

services, vocational and academic education 

services, and faith-based organization support. 

This ring represents some areas that are not 

typically included in the service array for 

women, but women’s treatment program staff 

and policy analysts increasingly view these 

elements as critical to long-term recovery. 

Over the last decade, the concept of relapse 

prevention and aftercare evolved into the 

approach known as continuing care. This 

approach recognizes both the need to provide 

continuing support to a person in recovery 

and that treatment providers share some of the 

responsibility for providing this support. The 

concept of community support operationalizes 

continuing care by recognizing the systems and 

services that must exist in the community in 

order to make continuing care a meaningful 

reality. 

278 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
Figure B-3 

Elements of Clinical Support Services 

Taken together, as shown in Figure B-4, clinical 

treatment, clinical supports, and community 

supports complete the basket and provide the 

comprehensive services needed by many women 

in substance abuse treatment. Implicit in the 

model is the responsibility of providers to look 

inward to their own resources as well as outward 

to community partners’ resources to ensure that 

the elements of comprehensive services are made 

available in the community. 

The Next Generation: 

Services for Children of 

Women in Substance 

Abuse Treatment 

While it is important to provide the 

comprehensive array of services and supports 

to all women, women who are also mothers 

demand increased attention to their unique roles 

as parents and their children require additional 

services and supports. Treatment agencies 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 279 
Figure B-4

Elements of Community Support Services 

280 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
have come to understand that, for women who 

are mothers, their children are a major factor 

influencing why they enter, complete, and/ 

or leave treatment. Mothers in treatment are, 

in most instances, the custodial parent who 

carries out the tasks of parenting and childrearing. In some cases, the mother in treatment 

may not currently have custody and the daily 

responsibility for the care of her children. 

Those cases require special considerations by 

treatment providers to assist the woman in her 

efforts to regain custody if appropriate, and, 

when regaining custody is not an option, assist 

the mother as she transitions in the loss of her 

children. 

Among mothers in treatment with custody of 

their children, the experience of the RWC and 

PPW programs is clear: Providing child care 

alone is an insufficient response to the needs of 

children whose mothers abuse alcohol and/or 

drugs. In many cases, the children themselves 

need services ranging from interventions for 

fetal alcohol spectrum disorders, to intervention 

services for childhood mental health disorders 

and developmental delays. Treatment programs 

have responded to the needs of children and 

have reported that treatment for women 

and their children requires a whole-family 

perspective in service delivery and in clinical 

practice. 

Figure B-5 

Clinical Treatment Services for Children 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 281 
Children’s clinical treatment needs are depicted 

in Figure B-5. Their clinical needs include 

intake; screening and assessment of the full 

range of medical, developmental, emotionalrelated factors; care planning; residential 

care; case management; therapeutic child care; 

substance abuse education and prevention; 

medical care and services; developmental 

services; and mental health and trauma services. 

In addition, children need supports that 

reinforce their individual needs. These clinical 

support services are shown in Figure B-6 and 

include the concepts of cultural competence 

and developmentally appropriate services. As 

with the women’s model, cultural competence is 

a critical aspect and is depicted as the handles 

for using the service array in the model. Needs 

and services for young children must be tailored 

to their developmental status and cognition. 

Clinical support services include primary health 

care, onsite or nearby child care, mental health 

and remediation services, prevention services, 

recreational opportunities, educational services 

and advocacy, advocacy in other service arenas 

and with legal issues, and peer supports for 

recovery such as self-help and mutual support 

groups. 

Regardless of the child’s current custody status, 

services to address children’s needs should be 

coordinated, and when appropriate, should 

be integrated with their primary caregivers’ 

treatment and case plans to ensure that the whole 

Figure B-6 

Clinical Support Services for Children 

282 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
family’s needs are met. Ensuring that parents’ 

and children’s case plans are in harmony in 

terms of timing and strategies is imperative for 

family recovery. While children can be signifi cant 

motivators for women to seek treatment, without 

proper planning, caring for children can also 

produce stress that may contribute to relapse. 

Taken together, providing comprehensive 

services for women and their children (as shown 

in Figure B-7) requires treatment agencies 

to provide an array of direct services and to 

establish linkages to a wide range of supports 

and community resources. This is no easy feat. 

The need for coordination and collaborative 

relationships among agencies and service 

systems can tax scarce resources in staff time 

and expertise to establish those bonds. While it 

may seem overwhelming to consider all of the 

various linkages needed, treatment agencies 

can prioritize their most immediate need for 

collaboration by understanding the most 

immediate needs of their clients. 

Putting the Elements 

Together 

The elements of treatment for women, including 

those who are mothers, are described below. 

Together the elements make up the continuum 

of services that women and women who are 

mothers need to succeed in substance abuse 

treatment. The intensity, duration, and type 

of treatment will vary depending upon the 

assessment and diagnosis of the woman and 

the needs of her child or children. The manner 

in which services are delivered will also vary, 

depending on factors specific to the woman and 

the child, including culture, race, ethnicity, 

social class, age, and sexual orientation. 

Treatment intensity, philosophy, and methods 

will vary depending on the needs of the client, 

reimbursement policies, and treatment methods 

used by providers. 

Clinical Treatment Services 

Clinical treatment services are generally 

provided directly by the substance abuse 

treatment provider. As such, they are 

considered core services. Providers recognize 

that providing core services without support 

services is likely to result in less than optimum 

outcomes for women and children over the 

longer term; thus, support services are pivotal to 

the successful treatment of women and children. 

Clinical treatment services for 

women 

• 	 Outreach, engagement, and pretreatment. 

Activities designed to assist clients in engaging 

in treatment are essential elements of service, 

falling into the broad category of outreach, 

engagement, and pretreatment services. For 

many women, these services break the ice and 

help them overcome the shame and denial 

that often serve as obstacles to treatment. 

Same-day services, visits to programs, and 

familiarization with program staff should be 

facilitated whenever possible. Identifi cation 

of and attention to women’s immediate needs 

(e.g., legal, health, safety) are important 

aspects of engagement, even if those problems 

cannot be resolved immediately. When a 

program slot is not immediately available, 

services should be offered to keep women 

connected to the treatment organization. 

Outreach for women must address barriers 

that keep women from treatment, such as 

fear of reprisal from significant others and 

family members, fear of not being able to 

care for children or the loss of custody, as 

well as language and/or cultural barriers. 

Outreach must also address systemic barriers 

such as lack of money or insurance, waiting 

lists, lack of treatment for pregnant women, 

absence of child care, lack of transportation, 

inability to find sustaining employment, and 

need for time to address demands of other 

systems, such as child welfare and TANF 

stipulations. 

• 	 Screening. Intake screening is part of the 

admissions process and can be an important 

strategy that assists in engaging a woman 

in treatment. As such, the interview should 

be relevant and sensitive to the woman’s 

immediate needs, including the needs of 

her children. Intake screening should be 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 283 
284 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model Figure B-7 Interrelated Elements of Clinical Treatment and Support Services for Women and Their Children 
conducted by a staff person, preferably a 

female, who is respectful of the complex 

needs of women, who is nonjudgmental, 

and who can determine critical immediate 

needs, including medical, prenatal care, 

detoxification, housing, safety, food, clothing, 

urgent dental needs, and transportation. 

Screening is a good opportunity to provide a 

complete explanation of confi dentiality and 

represents the beginning of the treatment 

engagement and case management process. 

• Detoxifi cation . Detoxifi cation services 

are generally provided in an inpatient or 

residential setting and generally include 

close medical supervision. Although some 

treatment providers consider detoxifi cation 

to be part of the continuum of care, others 

consider it a pretreatment activity. When 

needed, these services are critical to the 

comprehensive care model and offer another 

opportunity for a provider to engage a 

woman in longer-term treatment. 

• Crisis intervention. Women coming into 

treatment are often victims of violence and 

may be experiencing crises warranting 

emergency intervention. Ideally, programs 

would have crisis intervention specialists 

available or they may have established 

strong linkages for immediate access to crisis 

services. While some crises may be evident at 

intake, others may arise during the course of 

the treatment and may affect the woman and 

her children. 

• Assessment. Full assessment for women 

encompasses a wide range of concerns 

and includes a focus on her strengths; 

a comprehensive view of health-related 

needs; risks for HIV/AIDS and other 

infectious diseases; psychological status and 

screening and/or assessment for disorders 

that commonly co-occur in women with 

substance use disorders (e.g., depression 

and posttraumatic stress disorder [PTSD]); 

personal and community safety issues; 

understanding her signifi cant current 

relationships and family-of-origin factors that 

may predispose her to abuse substances (such 

as sexual, emotional, and physical abuse, 

neglect, parental addiction, and parental 

mental illness); her current parenting and 

caregiving roles; responsibility and issues 

such as custody of children, special needs 

of children living with the mother; options 

for care of children if the mother is to enter 

residential treatment without her children; 

her housing status and the safety of her 

housing; financial resources; vocational/ 

educational/employment issues; legal issues; 

and involvement with other health, social, 

and/or criminal justice service systems. Using 

the information garnered in the assessment 

process, a recommendation on the level of 

care and treatment placement should be 

made. The placement decisions should follow 

those promulgated by the American Society 

for Addiction Medicine (ASAM). Known as 

Patient Placement Criteria, ASAM’s criteria 

are increasingly the standard for determining 

the needed level of care. 

• Treatment planning. Treatment planning is a 

collaborative process that should be done in 

the context of the unique needs and informed 

choices of women, and should be based 

on their individual strengths. Treatment 

planning should include any immediately 

needed services to help stabilize the family 

and assist the woman as she prepares for 

treatment. It needs to build on the internal 

and external resources available to the 

agency and should integrate the assistance 

offered and stipulations required by other 

health and social service systems. Treatment 

planning with women and their children 

requires attention to re-entry and continuing 

care planning as well. 

• Case management. Case management 

addresses coordination of the myriad service 

elements that are needed by women and their 

families. Case management can occur as a 

pretreatment activity, during treatment, and 

posttreatment. Among services requiring 

coordination are medical, housing, child 

care, transportation, employment/vocational 

preparation, educational, and legal. 

Coordination with child protective services, 

welfare, and probation and parole offi ces 

must also be managed. 

• Substance abuse counseling and education. 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 285 
Substance abuse counseling and education 

for women needs to address the dynamics 

associated with addiction in women, as 

well as current behavioral issues in her 

addiction and the interrelationship between 

addiction and other co-occurring disorders. 

These include issues stemming from familyof-origin dynamics and the importance of 

relationships in the lives of women. It also 

needs to address the physical and social 

consequences of substance use disorders. 

Programs should ensure that all counseling 

activities are conducted in a respectful and 

caring manner and should not use counseling 

approaches that are contraindicated for 

trauma survivors, such as shaming, harsh 

confrontation, and intrusive monitoring. 

Staff should work with women in a manner 

that builds self-esteem, using nonaggressive 

and nonthreatening techniques so as not 

to revictimize clients. In addition, relapse 

prevention and recovery management are 

important components of substance abuse 

counseling and education. 

• Trauma-informed and trauma-specifi c 

services. Given the high prevalence of 

histories of violence among women with 

substance use disorders, providing treatment 

in a trauma-informed environment is 

especially important. Staff should be trained 

to understand the multiple and complex links 

between violence, trauma, and addiction; 

to understand trauma-related symptoms 

as attempts to cope; to understand that 

violence and victimization play large and 

complex roles within the lives of most 

consumers in substance abuse and mental 

health services; and to behave in ways that 

are not retraumatizing to women. Traumaspecific services include individual and group 

services that directly address the impact of 

trauma and facilitate recovery and healing. 

A woman should not have to disclose her 

trauma history to receive trauma-specifi c 

services. The best practice is to enter into 

every treatment relationship as if the woman 

has experienced trauma, whether disclosed 

or not. 

• Medical care, including treatment for 

infectious diseases, women’s health, and 

health education. Medical assessments and 

subsequent care should be provided onsite 

or by referral by care providers who are 

sensitive to gender, addiction, mental health, 

and trauma issues. The types of services 

that may be needed include primary care; 

prenatal and postnatal care; emergency and 

hospital care; chronic diseases care (arthritis, 

diabetes, etc.) and testing, treatment, and 

counseling for HIV/AIDS, tuberculosis, 

and sexually transmitted diseases; and 

gynecological care. During pregnancy, special 

consideration should be given to the medical 

management of the pregnancy. Maternal 

education about and preparation for delivery 

and postpartum needs, including postpartum 

relapse prevention, should be included. 

Methadone maintenance and medication 

management of opioid dependence is 

particularly important during pregnancy. 

For women with a history of mood disorder, 

the postpartum period should include close 

monitoring for psychiatric symptoms. 

• Pharmacotherapies. The use of methadone 

for treatment of opioid dependence is 

an accepted standard of care. Although 

usually provided on an outpatient basis, 

it should be available at all levels of care. 

Special attention may be needed when 

integrating patients on methadone and other 

phamacotherapies into treatment milieus 

with other clients who may not understand 

the utility of pharmacotherapies or who may 

have a negative attitude toward their use. 

• Mental health services. Provision of or 

linkage to psychiatric and psychological 

care providers is often needed, given the 

high prevalence of co-occurring psychiatric 

disorders among female substance abuse 

treatment clients. It is not unusual for women 

to need services for affective disorders, 

anxiety disorders (including PTSD), and 

somatization disorders. Services for other 

mental illnesses (including severe mental 

illnesses such as bipolar disorder or major 

depression) are not as common but are also 

needed. Pharmacotherapy is sometimes 

part of mental health care, and onsite staff 

can provide medication education and 

monitoring. 

286 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
• 	 Drug use monitoring. Drug use monitoring, 

as part of ongoing assessment of the client’s 

progress, is a component of treatment and 

can be used as a deterrent to relapse. 

• 	Continuing care. Continuing care is a critical 

element of clinical treatment services for 

women. Trusting relationships formed among 

women, their peers, and their counselors 

continue to provide support to women once 

they have completed the formal treatment 

period. Planning for discharge is often 

anxiety-provoking and counselors should 

be prepared for a recurrence of presenting 

problems and possible resistance and 

procrastination by the client. Continuing care 

takes place, ideally, in all three domains— 

clinical treatment, clinical supports, and 

community supportive services. It addresses 

individual needs identified in a woman’s 

relapse prevention plan, and builds a 

supportive network for the woman and 

her family to encourage and reinforce her 

recovery. When possible, a mother’s schedule 

of continuing care services and her child’s 

prevention services should be coordinated 

in order to encourage maximum attendance 

by both mother and child. A variety of selfhelp support programs can also promote the 

integration of the woman and her family into 

the community. 

Clinical treatment services for 

children 

• 	Intake. Substance abuse treatment agencies 

able to serve children should establish 

criteria that encourage enrollment of children 

in the program. In providing children with 

developmentally appropriate services, the 

agency’s criteria might consider the child’s 

age, as well as the number of children who 

may be involved for each mother. The child’s 

safety and well-being, including bonding 

and attachment issues, are paramount and 

any threats to these must be evaluated and 

considered in the intake criteria. 

• 	 Screening. Screening of children is an 

important part of providing family-centered 

and family-supportive treatment. Screening 

of children should be done in a supportive 

and friendly environment conducive to open 

dialog. There are advantages to having the 

same person conduct the screening who might 

later perform an assessment. 

• 	 Assessment. Medical, developmental, 

psychological, and trauma history should 

be assessed for all children participating in 

treatment with their mothers. Particular 

attention should be paid to issues that 

require immediate attention, such as 

methamphetamine lab exposure and physical 

abuse or severe neglect. As with screening, 

the assessment environment should be 

supportive, friendly, and conducive to open 

dialog. Determinations must be made as 

early as possible and should be continuously 

reviewed as to whether the child needs 

education, prevention services, intervention, 

treatment, or a combination of these. 

The child’s own support system should be 

assessed, including the role that the child’s 

father and extended family plays (or could 

play) in the child’s life. 

• 	Care planning. For children, care planning 

includes planning for education, prevention, 

and intervention services. Care planning 

should be conducted by professionals with 

particular experience in addressing the 

physical, psychological, and developmental 

needs of children whose mothers abuse 

alcohol and/or drugs. When age appropriate, 

it should include education about the 

treatment process that the mother will 

undergo and concerns about the transition 

that may be associated with that process. 

• 	 Residential care in residential settings. 

Providing safe and appropriate living space 

and adequate services for children whose 

mothers are in residential care is a powerful 

motivating factor for women to enter and 

continue in treatment. It enables children 

to either avoid separation or be reunited 

with the mother when treatment is made a 

condition of reunification by the courts. 

• 	Case management. In addressing the 

service needs of children of mothers with 

substance use disorders, special attention 

should be paid to coordinating the child’s 

services with those of the mother. Active 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 287 
involvement of the mother will aid in the 

transition from treatment program to home. 

Of critical importance to care for children 

are the dual concepts of personal safety 

and environmental stability. When children 

are not in their birth mothers’ custody, 

engagement of the foster or kin caregiver in 

care management is critical. 

• 	Therapeutic child care. Children born to 

mothers who use substances are at high risk 

for poor developmental outcomes including 

neurological effects and alcohol-related 

spectrum disorders as well as consequences 

stemming from preterm delivery. Living with 

a parent with an addiction may also result 

in mental health issues for the children, 

particularly those associated with witnessing 

violence or separation from primary 

caregivers. Children with medical and mental 

health disabilities may need specialized 

child care provided by professionals with 

advanced training and in a setting where 

accommodations can be made to the physical 

environment that are responsive to these 

disabilities. 

• 	 Substance abuse education and prevention. 

Children whose mothers have substance use 

disorders need substance abuse education 

and prevention support at an early age, in 

part to correct their misconceptions of what 

is normal adult behavior. These programs 

should present information about the role 

of substances in the mother’s role in caring 

for her children and to put the mother’s 

treatment in the context of the child’s view of 

reality. 

• 	 Medical care and services. In addition to 

a need for primary health care, attention 

must be given to the possibility of organic 

damage resulting from prenatal or early 

childhood substance exposure. This includes 

the physiological damage of alcohol-related 

spectrum disorders and exposure to drug 

production such as methamphetamine. 

Medical assessments and subsequent care 

should be provided onsite when possible or 

by referral when necessary. The types of 

services that may be needed include neonatal 

and perinatal care; pediatric care; emergency 

and hospital care; and testing, treatment, 

and counseling for pediatric HIV/AIDS. 

• 	 Developmental services. Children who have 

been exposed to alcohol or drugs in utero or 

within their family environment may be at 

risk for physical and cognitive developmental 

delays. Physical, occupational, and speech 

therapy may be indicated for these children. 

Children experiencing developmental delays 

may also require behavior modifi cation 

support, tutoring, and medication that will 

need to be managed. 

• 	 Mental health and trauma services. 

Children who grow up in the care of adults 

with substance use disorders can suffer 

psychological distress resulting from the 

experience of neglect as well as emotional, 

physical, or sexual abuse. Some children 

have witnessed domestic or other acts of 

violence. Children of mothers with substance 

use disorders often benefit from psychological 

counseling and therapy and from having 

their own trauma issues addressed through 

individual and group modalities. 

Clinical Support Services 

Clinical support services assist women in making 

the transition to independent and healthy 

alcohol- and drug-free living. They introduce 

or stabilize the woman’s ability to care for 

herself and her family and to fulfill her role as 

a community and family member. For children, 

these services support healthy development and 

increase their capacity to reach their potential. 

Clinical support services for 

women 

• 	Primary health care services. Primary 

health care services, which are often 

provided at the beginning of the treatment 

episode, are clinical support services (as 

opposed to medical interventions such as 

detoxification and related triage services 

considered clinical treatment services). These 

clinical support medical services include 

obstetric and gynecologic services, HIV/AIDS 

288 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
counseling, general medical and dental care, 

nutrition counseling, eating behavior issues, 

family planning, reproductive health, health 

education, and physical and exercise therapy. 

Also critical to primary health care for 

women are medical self-awareness, personal 

hygiene, and self-advocacy for wellness. 

• Life skills. Life skills include all of the 

activities that support independent, healthy 

lifestyles. They include budgeting and 

banking; negotiating access to services such 

as housing, English as a second language, 

income support including access to TANF, 

food stamps, and Medicaid; navigating legal 

services and commitments; setting up and 

running a household; grooming and clothing; 

recreation and leisure; nutrition; using 

public transportation; and arranging for 

child care. 

• Parenting and child development education. 

Treatment for women with children is 

optimized and interaction between the 

mother and child is improved when the 

women’s role as a mother is acknowledged 

and incorporated throughout treatment. 

Parenting skills are improved through 

education about child development and 

caretaking, skill building, and addressing 

shame and guilt over past parenting 

activities. Mothers who are being reunited 

with children will need support in 

preparation for and after the reunion. 

Fathers can also be important contributors 

to the well-being of their children, and when 

possible, should receive the education and 

support necessary to prepare them for the 

responsibility of parenthood. 

• Family programs. The more psychologically 

and emotionally healthy a woman’s 

significant others are, the more likely they 

are to help her remain engaged in treatment 

and recovery. Significant others should be 

involved in understanding family members’ 

roles in the family and how those roles may 

have become maladaptive coping strategies 

while the woman was in active addiction. 

When significant others are directly involved 

in relapse prevention planning, they are 

more likely to become productively involved 

in supporting positive efforts at recovery 

and intervening on relapse warning signs. 

Family-centered programs address all 

members in the family and include efforts 

to improve relationships with signifi cant 

others, including partners, parents, siblings, 

children, and caretakers. These family 

interventions can be an important part of the 

woman’s preparation for long-term recovery. 

• Educational remediation and support. 

Educational deficiencies may be a 

consequence of a woman’s addiction or may 

be a significant contributor to her addiction. 

A lack of education is reflected in poor 

reading skills, conduct issues, illiteracy, 

special education needs, low family income, 

and psychological barriers associated with 

poor performance and low self-esteem. 

Cognitive impairments due to alcohol-related 

spectrum disorders and other congenital or 

biological origins may require signifi cant 

educational supports. Establishing linkages 

and/or services to address these educational 

issues may be signifi cant motivators 

for women to remain in treatment and 

provide hope for her to establish economic 

independence. 

• Employment readiness services. Given the 

relationship of meaningful employment to 

recovery success and societal pressures to 

move the unemployed to the workforce, 

employment readiness services are an 

essential element of treatment. These 

services include reading and numeric skills 

testing, literacy tutoring, GED classes, 

vocational assessments, pre-employment 

readiness training (soft skills), job referral, 

job retention services, and transitional 

employment placement. Treatment programs 

should establish as one of their goals the 

self-sufficiency of the client, seeking effective 

linkages with TANF and child welfare 

agencies. 

• Linkages with the legal and child welfare 

systems. Many women in treatment have 

conditions set by the child welfare system 

to maintain their parenting role or for 

reunification with children who may have 

been removed from the mother’s custody. 

These requirements often include reports 

that progress is being made toward treatment 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 289 
goals, completion of parenting and anger 

management programs, supervised visits, 

drug testing, and court appearances. 

Communication among treatment providers, 

child welfare workers, the mother’s legal 

advocate, and the dependency court helps 

women move toward these goals. When 

mothers are also involved in the criminal 

justice system, linkages and communication 

with probation and parole staff are also 

critical. Criminal justice requirements may 

include drug testing, court appearances, and 

documentation regarding treatment progress 

toward goals. Often these communications 

require access to the community’s legal aid 

services. 

• 	Housing support services. For women, 

particularly women with children, housing 

represents more than just shelter. It is a 

crucial support for recovery. It represents 

safety both for her and for her children. 

Thus, a comprehensive care provider must 

address the issue of where the woman will 

reside when she completes treatment and 

make the provision for adequate housing a 

part of the program’s continuum of care. 

Given the time involved in arranging for 

affordable, safe, drug-free housing, this 

service needs to be part of early planning. 

• 	 Advocacy. Women entering treatment 

often require advocates to assist them in 

negotiating the various systems they may 

need to interact with. Although direct 

advocacy services provide immediate access 

to remediation, the goal of this process is to 

transform women into empowered individuals 

who can effectively advocate for themselves 

and their families. 

• 	 Recovery community support services. 

Regardless of the treatment model or 

modality, women need to appreciate that they 

are not alone and that others have traveled 

the same road. It is critical for women to be 

supported in developing relationships with 

other women and persons in recovery who 

can be role models and provide support, 

friendships, and companionship in pursuing 

safe and sober leisure activities. Thus, early 

in the treatment process, providers must help 

women develop a gender-sensitive support 

network within the recovery community. 

• 	Clinical support services for children 

• 	Primary health care services. Primary 

health care services are an ongoing need 

for children of mothers with substance use 

disorders. Monitoring medical conditions 

should include screening for a range of 

potential medical complications including 

effects resulting from prenatal substance 

exposure and risks of HIV/AIDS and other 

communicable diseases. Primary health care 

services should also focus on wellness and 

prevention, including immunizations and 

regular medical examinations. 

• 	 Onsite or nearby child care. Developmentally 

appropriate, quality child care is needed 

for children whose mothers participate in 

treatment. Child care should be onsite or 

proximate to the program and should include 

a full range of services, from therapeutic 

child care to developmentally appropriate 

interventions and recreational play. 

• 	 Mental health and remediation services. 

Children whose mothers abuse alcohol and/ 

or drugs often have developmental delays 

that require specific interventions. These 

children may experience higher rates of 

attention deficit disorder, attention defi cit/ 

hyperactivity disorder, conduct disorder, 

speech and language delays, and learning 

disabilities. 

• 	Prevention services. Children whose mothers 

have substance use disorders are at higher 

risk of developing a substance use disorder 

of their own as they enter preadolescence 

and adolescence. Evidence-based prevention 

services tailored to these children may be 

most appropriate when offered in the context 

of the parent’s own history and recovery. 

Prevention programs that have demonstrated 

their effectiveness with a range of child and 

adolescent populations can be found at http:// 

modelprograms.samhsa.gov. 

• 	 Recreational services. Participation in 

pleasurable recreational activities helps 

children socialize, express themselves, 

relax, experience new activities, and become 

knowledgeable about healthful alcohol- and 

drug-free leisure activities. Participation in 

developmentally appropriate recreational 

290 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
activities is a critical learning experience for 

children. Participation in sports, hobbies, 

and creative outlets can also provide vehicles 

for enhanced self-image and self-esteem. 

• 	Educational services. The needs of schoolage children, including attention to academic 

progress, are a necessary part of each child’s 

service plan. Often, children in treatment 

with their mothers experience disruption 

in their academic experience because of 

frequent moves or other family crises. 

Children who were prenatally exposed 

to substances may have ongoing learning 

disabilities that require advocacy to ensure 

special education services are available and 

to ensure children’s academic success. When 

regular reviews of individual education plans 

are needed, the treatment agencies must 

recognize the critical role that the mother 

may play in attending such sessions. 

• 	 Advocacy. Mothers with substance use 

disorders may not be effective advocates 

for their children. Programs may need to 

provide direct advocacy services as well as 

assist mothers in developing appropriate 

advocacy skills to ensure that they are able 

to negotiate for the needs of their children. 

Children, as well, should be introduced 

to advocacy skills when developmentally 

appropriate. 

• 	 Recovery community support services. 

Because of the significant impact of peers 

and role modeling on the development of 

children, there is a marked need for ageappropriate recovery support activities. By 

building their own community of support, 

children can identify with peers and learn 

from those who have coped with similar 

experiences. 

Community Support 

Services 

Community support services are those services 

that extend beyond the treatment program and 

are found within the community. These services 

help to ensure that short-term treatment success 

can be sustained in long-term recovery. While 

there are additional services that women, 

children, and other family members may 

need in order to support the recovery of the 

family, those included below represent the 

more common services used by families as they 

progress in their recovery. 

• 	 Recovery management and recovery 

community support services. Communitybased recovery management services include 

activities that provide relapse prevention 

and continuing care. While these services 

may begin during treatment, they are part of 

the community-based network that supports 

recovery. Consistent with the importance of 

women’s personal relationships, women will 

benefit from the availability of peer-driven 

recovery mutual support services, which can 

include Alcoholics Anonymous, Narcotics 

Anonymous, and Women for Sobriety. 

• 	Housing services. Adequate housing is 

essential both for safety and for security. 

While housing services are often placed 

within clinical support services, in the 

context used here, housing services are also 

a community infrastructure issue. In this 

context, housing which encourages alcoholand drug-free living can be a vital component 

for sustaining recovery. 

• 	 Family strengthening. Recognizing the family 

disruption that is common to addiction, 

women (particularly those who are heads of 

their households), need services that support 

the re-establishment of important family ties, 

including ongoing family therapy and family 

support services. 

• 	Child care. This is both an immediate and 

short-term treatment support service as 

well as a broader community service. As a 

community support, quality preschool, child 

care, and after-school care programs are 

longer-term needs that enable mothers to 

work outside the home. 

• 	Transportation . Accessible and reliable 

transportation is important given 

the complicated schedules of women 

caretakers who often have to balance the 

transportation needs of their children with 

the transportation needs of employment and 

ongoing participation in continuing care. 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 291 
• 	TANF linkages . With some exceptions, 

women from lower socioeconomic strata 

who progress through treatment are either 

TANF eligible or may become TANF eligible. 

TANF agencies have a role to play in 

providing support for recovery by serving 

as a bridge between the three circles of 

clinical treatment, with an emphasis on work 

preparation and sustaining employment for 

women going through the recovery process. 

• 	Employer support services. Communities 

need to create systems within employment 

settings that support recovery and combat 

workplace substance abuse. Larger 

employers may offer employee assistance 

programs and smaller employers may be 

able to coordinate needed job support 

services with treatment providers from their 

communities. 

• 	 Vocational and academic education 

services. Critical to recovery success is the 

continuation of educational and vocational 

services that are begun during treatment. 

• 	 Faith-based organization support . 

Recognizing that spirituality plays a crucial 

role in the recovery process, it is important 

that connections are established by treatment 

providers with faith-based institutions 

that can serve as appropriate resources 

for addressing the spiritual issues related 

to addiction and recovery. Faith-based 

organizations can play an important role in 

the community and can connect families in a 

supportive community network. 

Funding Issues 

Finally, in response to the needs of providers 

to understand funding options for this array 

of services, this revision to the model allows 

providers to identify discrete elements of the 

comprehensive model and to make their own 

assessments of how to finance the elements 

through available funding streams. For some 

elements, funding will be readily available 

and sufficient to cover the full cost of services 

delivery. Other elements, such as continuing 

care and many of the services for children, are 

not as easily supported; providers will have to 

use more flexible funding to cover these services 

while they continue to communicate to funders 

that unfunded and underfunded components are 

critical elements in the comprehensive model of 

care. 

Providing comprehensive services through 

the separate agencies serving women and their 

children involves connecting the multiple 

funding streams that flow into the various 

health, human service, and educational agencies 

serving families. The more comprehensively 

a continuum of care is defined, the wider the 

array of funding streams that is needed. The 

more committed an agency is to family-centered 

services, the more mastery is needed of all the 

different funding streams that can support 

families. No single agency has adequate funding 

sources by itself to achieve comprehensive 

outcomes; interagency funding streams are 

therefore critical to converting hopes for new 

linkages into reality. 

Fiscal context always matters, and in tight fi scal 

climates, tapping new sources of funding is both 

desired and resisted. It is desired for the obvious 

reason that hard-pressed agencies are anxious 

to find alternative funding streams to support 

their programs; it is resisted for the equally 

obvious reason that agencies seek to protect 

their own funding streams even more when 

funding is tight. The descriptions of funding 

and suggestions that follow are made in full 

awareness that in most States, fi scal constraints 

are very significant factors at present. 

Several issues affect the ability of programs 

to provide the comprehensive services needed 

by women and children affected by substance 

use disorders. Some of these issues are based 

on the nature of the collaborative relationship 

between the agencies, some flow from categorical 

funding constraints, and some are based on 

other Federal or State policies. Understanding 

which of these barriers are affecting a State’s or 

community’s ability to provide comprehensive 

services is a critical first step in developing 

its response. These concerns may include the 

following: 

292 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
• 	Existing categorical definitions of funding 

streams and eligibility restrictions can create 

barriers to interagency efforts, with agency 

officials sometimes resistant to what seems 

like “one more earmark” on funding streams. 

• 	 Decisions by agencies to provide services 

directly or to negotiate for services with 

outside agencies are critical choices, but at 

times they may be made based on limited 

understanding of other agencies’ funding 

streams. 

• 	Each system sees the other’s funding streams 

as mysterious and difficult to access, and 

each sees its own as overcommitted and 

possibly threatened, leading to a debate over 

“your money, our money, or their money.” 

• 	A sustained, time-consuming effort is 

required to achieve new Federal, State, and 

local collaboration, which is needed to create 

financing responsive to the multiple needs of 

children and families. 

• 	As the majority of funding fl ows through 

State-level government, State systems 

may need specific legislation to overcome 

categorical requirements. 

• 	There are signifi cant fi nancial incentives 

to maintain the status quo in fragmented 

funding streams. 

• 	Categorically funded programs that do not 

apply adequate “dosage” to ensure treatment 

effectiveness may require additional layers 

of funding from additional sources to get 

to scale and provide an adequate dosage of 

services. For example, programs that do not 

provide aftercare services to parents may be 

unable to respond to relapse issues, resulting 

in readmission to treatment that was 

underfunded but that ends up with a higher 

overall cost due to clients’ readmission. 

Unified Fiscal Planning 

The concept of unifi ed fiscal planning has 

been introduced recently. This approach 

includes a variety of strategies used by States 

and communities to create and sustain an 

integrated and flexible continuum of care for 

children and families (Crocker 2003). Some 

of the more commonly used strategies include 

decategorization, pooled funding, blended 

funding, braided funding, wraparound services, 

and refinancing. Often the terms are used 

interchangeably or without clear defi nition; 

however, the following are common defi nitions 

used for these concepts: 

• 	 Decategorization refers to State-level 

efforts to reduce or eliminate categorical 

requirements on how funds are spent. This 

reduction in requirements is often created in 

exchange for greater accountability for a set 

of negotiated outcomes. 

• 	Pooled or blended funding is generally a 

local-level effort that is implemented among 

a group of agencies that formally integrates 

a set of funding streams into a single source 

of dollars. A new funding structure is often 

developed that administers and allocates the 

funds to the participating agencies based on 

negotiated contracts. 

• 	Braided funding is generally implemented 

by an individual agency or program and 

refers to administrative efforts to obtain 

multiple funding sources to create more 

comprehensive services. This strategy 

typically works within the categorical 

system and administrative responsibilities 

for maintaining the various categorical 

requirements remain. 

• 	 Wraparound services. The term 

“wraparound” came into use in 1986, in an 

article by Lenore Behar, who defined it as a 

way to “surround multi-problem youngsters 

and families with services rather than with 

institutional walls, and to customize these 

services” (Behar 1986). The wraparound 

approach is more a process than a service, in 

which a child’s or family’s individual needs 

are addressed by the full range of services 

they need, with maximum fl exibility in 

funding. 

• 	 Refi nancing . “Refi nancing entails 

aggressively pursuing monies from uncapped 

Federal appropriations such as entitlement 

funds, using these new Federal funds to pay 

for standard services, and then applying 

the freed-up local and State funds to pay 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 293 
for alternative programs, including... 

comprehensive service initiatives” (Orland 

1995). 

Specifi c Treatment-Related 

Funding Streams 

While the Substance Abuse Prevention and 

Treatment Block Grant is still the largest source 

of publicly supported substance abuse treatment 

(approximately 40 percent), treatment providers 

should become familiar with the Medicaidreimbursable services in their States and learn 

how to bill for these services. Medicaid is a 

joint Federal–State entitlement program and 

the third largest source of health insurance in 

the country. It makes up approximately one 

quarter of public funds available for treatment. 

Medicaid coverage varies from State to State. 

Nearly all States restrict services when paying 

for alcohol and drug abuse treatment. The 

types of restrictions include low payment rates 

for treatment providers, restrictions on the 

settings for treatment, low limits on the days of 

inpatient treatment, low limits on the number 

of outpatient visits, and restrictions on types of 

providers that can be reimbursed (Legal Action 

Center 2002). 

The Medicaid codes published by the Centers 

for Medicare and Medicaid Services (CMS) are 

also known as the HCPCS codes (Health Care 

Financing Administration Common Procedure 

Coding System). With few exceptions, all of the 

services described here as clinical treatment 

services for women have applicable HCPCS 

codes. There are fewer applicable HCPCS codes 

for the clinical support services for women, 

and HCPCS codes do not apply to community 

support services. As noted earlier, the existence 

of a code does not necessarily mean that a State 

reimburses for a service (at any level). States are 

only responsible for a short list of mandatory 

services, whereas most services are optional 

reimbursable services. The CMS updates the 

HCPCS codes on an annual basis. Information 

on applicable alcohol, drug, and behavioral 

health HCPCS codes can be found on the Web 

site of the National Association of State Alcohol 

and Drug Abuse Directors (www.nasadad.org). 

In addition to the mandatory and optional 

Medicaid alcohol and drug benefi ts, Medicaid 

includes a benefit known as Early and Periodic 

Screening, Diagnostic, and Treatment (EPSDT) 

to cover both prevention and treatment services 

for children and adolescents under age 21. All 

children enrolled in Medicaid are entitled to 

EPSDT. “Under EPSDT, States must screen and 

then furnish appropriate medically necessary 

treatment to ‘correct or ameliorate defects 

and physical and mental illness and conditions 

discovered by the screening services’” (Legal 

Action Center 2002, p. 10). In practice, use of 

this resource has been limited by States’ ability 

to pay for the services. An additional source of 

funding for uninsured, low-income children is 

the State Children’s Health Insurance Program, 

which is allocated by block grant formula to the 

States. 

TANF can fund a range of nonmedical clinical 

treatment services as well as clinical and 

community support services for both women and 

children. The extent to which this is used varies 

greatly from State to State. Other additional 

valuable funding sources are available for 

many of the services described, although many 

are time-limited and/or specialized, increasing 

the time demands on the provider to seek and 

manage multiple funding streams. 

Closing Considerations 

In designing a comprehensive substance abuse 

treatment model for women and their children, 

CSAT is not attempting to articulate every 

element of treatment for this population. 

Rather, CSAT wishes to provide a standard 

or goal to which programs should aspire as 

they design and plan services that will be 

characterized as holistic, wraparound, and/or 

comprehensive. Additionally, it is not CSAT’s 

intention to see this model adopted without 

reference to the context of the community in 

which it is used. Thus, for the model to be truly 

comprehensive, it should be more than adopted; 

it should be adapted to its community and its 

consumers. 

294 Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 
In adapting this model, different communities 

will emphasize different aspects. For example, 

the American Indian and Alaska Native 

communities have demonstrated the special role 

that spirituality, culture, and historical trauma 

play in treatment, and for these communities, 

a worthwhile adaptation requires an increased 

emphasis on these issues. For a community of 

older women, an emphasis on medication abuse 

may also be appropriate. 

This model embodies the best practices known 

to CSAT, as well as the agency’s experience in 

addressing this issue on a nationwide basis. 

Appendix B: CSAT’s Comprehensive Substance Abuse Treatment Model 295 
Appendix C: Screening 

and Assessment 

Instruments 

Addiction Severity Index (ASI) 

Purpose: The ASI is most useful as a general intake screening tool. It 

effectively assesses a client’s status in several areas, and the composite 

score measures how a client’s need for treatment changes over time. 

Clinical utility: The ASI has been used extensively for treatment 

planning and outcome evaluation. Outcome evaluation packages for 

individual programs or for treatment systems are available. 

Groups with whom this instrument has been used: Designed for 

adults of both sexes who are not intoxicated (drugs or alcohol) when 

interviewed. 

Norms: The ASI has been used with males and females with drug and 

alcohol disorders in both inpatient and outpatient settings. Female 

version: ASI-F. 

Format: Structured interview 

Administration time: 50 minutes to 1 hour 

Scoring time: 5 minutes for severity rating 

Computer scoring? Yes 

Administrator training and qualifi cations: A self-training packet is 

available as is onsite training by experienced trainers. 

Available from: 

A. Thomas McLellan, Ph.D. 

Building 7 

PVAMC 

University Avenue 

Philadelphia, PA 19104 

Ph: (800) 238-2433 

Appendix C: Screening and Assessment Instruments 297 
Clinical Institute 

Withdrawal Assessment 

(CIWA-Ar) 

Purpose: To track severity of withdrawal and 

measure severity of alcohol withdrawal. 

Clinical utility: Aid to adjustment of care 

related to withdrawal severity. 

Groups with whom this instrument has been 

used: Adults 

Norms: N/A 

Format: A 10-item scale for clinical 

quantification of the severity of the alcohol 

withdrawal syndrome. 

Administration time: 2 minutes 

Scoring time: 4 to 5 minutes 

Computer scoring? No 

Administrator training and qualifi cations: 

Training is required, and the CIWA is 

administered by nurses, doctors, research 

associates/detoxification unit workers. 

Fee for use: No 

Available from: 

Dr. E.M. Sellers 

Ventana Clinical Research Corporation 

340 College Street, Suite 400 

Toronto, Canada 

M5T 3A9 

Phone: 416-963-9338 

Fax: 416-963-9732 

www.ventana-crc.com/ 

Level of Care Utilization 

System (LOCUS) 

Purpose: To assess immediate service needs 

(e.g., for clients in crisis); to plan resource needs 

over time, as in assessing service requirements 

for defined populations; to monitor changes in 

status or placement at different points in time. 

Clinical utility: LOCUS is divided into three 

sections. The fi rst defines six evaluation 

parameters or dimensions: (1) Risk of Harm, 

(2) Functional Status, (3) Medical, Addictive, 

and Psychiatric Co-Morbidity, (4) Recovery 

Environment, (5) Treatment and Recovery 

History, and (6) Engagement. A fi ve-point scale 

is constructed for each dimension, and the 

criteria for assigning a given rating or score in 

that dimension are elaborated. In dimension 

IV, two subscales are defined, whereas all other 

dimensions contain only one scale. 

Groups with whom this instrument has been 

used: Adults 

Norms: N/A 

Format: A document that is divided into three 

sections. 

Administration time: 15 to 30 minutes 

Scoring time: 20 minutes 

Computer scoring? No 

Administrator training and qualifi cations: N/A 

Fee for use: No 

Available from: American Association of 

Community Psychiatrists 

www.wpic.pitt.edu/aacp/fi nd.html 

298 Appendix C: Screening and Assessment Instruments 
Eating Attitudes Test (EAT-26) 

The following screening questionnaire is designed to help you determine if your eating behaviors and attitudes warrent further 

evaluation. The questionnaire is not intended to provide a diagnosis. Rather, it identifi es the presence of symptoms that are 

consistent with either a possible eating disorder. 

Answer thes as honestly as you can, and then score questions using the instructions at the end. 

Please mark a check to the right of each of 

the following statements: Always Usually Often Sometimes Rarely Never Score 

1. Am terrifi ed about being overweight.       

2. Avoid eating when I am hungry.       

3. Find myself preoccupied with food.       

4. Have gone on eating binges where I feel 

that I may not be able to stop. 

      

5 Cut my food into small pieces.       

6. Aware of the calorie content of foods that I 

eat. 

      

7. Particularly avoid food with a high       

carbohydrate content (i.e. bread, rice, 

potatoes, etc.) 

8. Feel that others would prefer If I ate more.       

9. Vomit after I have eaten.       

10. Feel extremely guilty after eating.       

11. Am preoccupied with a desire to be 

thinner. 

      

12. Think about burning up calories when I 

exercise. 

      

13. Other people think that I am too thin.       

14. Am preoccupied with the thought of 

having fat on my body. 

      

15. Take longer than others to eat my meals.       

16. Avoid foods with sugar in them.       

17. Eat diet foods       

18. Feel that food controls my life.       

19. Display self-control around food.       

20. Feel that others pressure me to eat.       

21. Give too much time and thought to food.       

22. Feel uncomfortable after eating sweets.       

23. Engage in dieting behavior.       

24. Like my stomach to be empty.       

25. Have the impulse to vomit after meals.       

26. Enjoy trying new rich foods.      

Total Score = 



Appendix C: Screening and Assessment Instruments 299 
Eating Attitudes Test (EAT-26) (continued)
 

A) Have you gone on eating binges where you feel that you may not be able to stop? __ No Yes __ How many times in the last 

6 months? _______ 

B) Have you ever made yourself sick (vomited) to control your weight or shape? __ No Yes __ How many times in the last 6 

months? _______ 

C) Have you ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? __ No Yes __ How many 

times in the last 6 months? _______ 

D) Have you ever been treated for an eating disorder? __ No Yes __ When? _______ 

EAT-26’ David M. Garner (1982) Note: The EAT-26 has been made available with permission of the authors. 

Step 1: 

EAT-26 ITEM SCORING 

Score each item as indicated below and put score in box 

to the right of each item 

Items # 1-25: Item # 26 only: 

Always = 3 = 0 

Usually = 2 = 0 

Often = 1 = 0 

Sometimes = 0 = 1 

Step 2: Total EAT-26 Score 

Total = 

Add item scores together for a Total 

EAT-26 score: 

Step 3: Behavioral Questions 

Total = 

Did you score Yes on Questions A, B, 

C or D? 

Step 4: Underweight 

Determine if you are signifi cantly underweight according 

to the table to the right 

Step 5: Referral No Yes 

If your EAT-26 score is 20 or more 

or if you answered YES to any questions A-D 

or if your weight is below the number on 

the weight chart to the right 

Please discuss your results with your physician or 

therapist 

Signifi cantly Underweight According 

to Height 

(Body Mass Index of 18)* 

Height 

(inches) 

Weight 

(pounds) 

Height 

(inches) 

Weight 

(pounds) 

58 86 68 118 

58 88 68 120 

59 89 69 121 

59 90 69 124 

60 91 70 125 

60 93 70 127 

61 95 71 128 

61 96 71 131 

62 99 72 132 

62 100 72 134 

63 101 73 135 

63 103 73 138 

64 105 74 140 

64 106 74 141 

65 108 75 144 

65 109 75 146 

66 112 76 147 

66 113 76 149 

67 114 77 152 

67 117 77 154 

× 

300 Appendix C: Screening and Assessment Instruments 
*Note: The table on the previous page indicates the body weights for heights considered to be “significantly underweight” according to a Body Mass Index (BMI) of 18. BMI is a simple method of 

evaluating body weight taking height into consideration. It applies to both men and women. There 

is some controversy regarding whether or not BMI is the best method of determining relative body 

weight and it is important to recognize that it is possible for someone to be quite malnourished 

even though they are above the weight listed in the table. In order to determine if you are “signifi ­

cantly underweight”, locate your height (without shoes) on the table and see if the corresponding 

body weight (in light indoor clothing) is below that listed. If so, you are considered “signifi cantly 

underweight” and should speak to your physician or therapist about your weight. To Calculate 

Body Mass Index (BMI) exactly; Weight (pounds) Divided by Height in Inches; Divide this again 

by Height in Inches and Multiply by 703 

BMI = (lbs) ÷ (inches) ÷ (inches) × 703 

Spiritual Well-Being Scale 

(SWBS) 

Purpose: A general indicator of well-being 

that may be used for the assessment of both 

individual and group spiritual well-being. It 

provides an overall measure of the perception 

of spiritual quality of life, as well as subscale 

scores for Religious and Existential Well-Being. 

The Religious Well-Being subscale provides a 

self-assessment of one’s relationship with God, 

while the Existential Well-Being Subscale gives a 

self-assessment of one’s sense of life purpose and 

life satisfaction. 

Clinical utility: The SWBS is composed of 20 

items, 10 of which assess religious well-being 

specifically, and 10 of which assess existential 

well-being. 

Groups with whom this instrument has been 

used: Adults and children 

Norms: Yes 

Format: The SWBS is a paper-pencil instrument 

currently available in English and Spanish. 

Administration time: 10-15 minutes 

Scoring time: Information not available 

Computer scoring? Information not available 

Administrator training and qualifi cations: 

Information not available 

Fee for use: Yes 

Available from: 

Life Advance, Inc. 

81 Front Street 

Nyak, NY 10960 

Lifeadvance.com 

Appendix C: Screening and Assessment Instruments 301 
Drinker Inventory of Consequences (DrInC-2L) 

Instructions: Here are a number of events that drinkers sometimes experience. Read each one 

carefully, and circle the number that indicates whether this has EVER happened to you (0 = No, 1 = 

Yes). If an item does not apply to you, circle zero (0). 

Has this EVER happened to you? No Yes 

1. I have had a hangover or felt bad after drinking. 0 1 

2. I have felt bad about myself because of my drinking. 0 1 

3. I have missed days of work or school because of my drinking. 0 1 

4. My family or friends have worried or complained about my drinking. 0 1 

5. I have enjoyed the taste of beer, wine, or liquor. 0 1 

6. The quality of my work has suffered because of my drinking. 0 1 

7. My ability to be a good parent has been harmed by my drinking. 0 1 

8. After drinking, I have had trouble with sleeping, staying asleep, or

 nightmares. 0 1 

9. I have driven a motor vehicle after having three or more drinks. 0 1 

10. My drinking has caused me to use other drugs more. 0 1 

11. I have been sick and vomited after drinking. 0 1 

12. I have been unhappy because of my drinking. 0 1 

13. Because of my drinking, I have not eaten properly. 0 1 

14. I have failed to do what is expected of me because of my drinking. 0 1 

15. Drinking has helped me to relax. 0 1 

16. I have felt guilty or ashamed because of my drinking. 0 1 

Has this EVER happened to you? No Yes 

17. While drinking I have said or done embarrassing things. 0 1 

302 Appendix C: Screening and Assessment Instruments 
 

18. When drinking, my personality has changed for the worse. 0 1 

19. I have taken foolish risks when I have been drinking. 0 1 

20. I have gotten into trouble because of drinking. 0 1 

21. While drinking or using drugs, I have said harsh or cruel things to 

someone. 

0 1 

22. When drinking, I have done impulsive things that I regretted later. 0 1 

23. I have gotten into a physical fight while drinking. 0 1 

24. My physical health has been harmed by my drinking. 0 1 

25. Drinking has helped me to have a more positive outlook on life. 0 1 

26. I have had money problems because of my drinking. 0 1 

27. My marriage or love relationship has been harmed by my drinking. 0 1 

28. I have smoked tobacco more when I am drinking. 0 1 

29. My physical appearance has been harmed by my drinking. 0 1 

30. My family has been hurt by my drinking. 0 1 

31. A friendship or close relationship has been damaged by my drinking. 0 1 

32. I have been overweight because of my drinking. 0 1 

33. My sex life has suffered because of my drinking. 0 1 

34. I have lost interest in activities and hobbies because of my drinking. 0 1 

35. When drinking, my social life has been more enjoyable. 0 1 

36. My spiritual or moral life has been harmed by my drinking. 0 1 

37. Because of my drinking, I have not had the kind of life that I want. 0 1 

Has this EVER happened to you? No Yes 

38. My drinking has gotten in the way of my growth as a person. 0 1 

39. My drinking has damaged my social life, popularity, or reputation. 0 1 

40. I have spent too much or lost a lot of money because of my drinking. 0 1 

Appendix C: Screening and Assessment Instruments 303 
41. I have been arrested for driving under the influence of alcohol. 0 1 

42. I have had trouble with the law (other than driving while intoxicated) because of my drinking. 0 1 

43. I have lost a marriage or a close love relationship because of my 

drinking. 0 1 

44. I have been suspended/fired from or left a job or school because of 

my drinking. 0 1 

45. I drank alcohol normally, without any problems. 0 1 

46. I have lost a friend because of my drinking. 0 1 

47. I have had an accident while drinking or intoxicated. 0 1 

48. While drinking or intoxicated, I have been physically hurt, injured, 

or burned. 0 1 

49. While drinking or intoxicated, I have injured someone else. 0 1 

50. I have broken things while drinking or intoxicated. 0 1 

304 Appendix C: Screening and Assessment Instruments 
Appendix C: Screening and Assessment Instruments 305 
306 Appendix C: Screening and Assessment Instruments 
Appendix D: Allen Barriers 

to Treatment Instrument 

Appendix D: Allen Barriers to Treatment Instrument 307 
308 Appendix D: Allen Barriers to Treatment Instrument 
Appendix D: Allen Barriers to Treatment Instrument 309 
Appendix E: 

DSM-IV-TR Criteria for 

Posttraumatic Stress 

Disorder 

A. 	 The person has been exposed to a traumatic event in which both of 

the following were present: 

(1) 	 The person experienced, witnessed, or was confronted with 

an event or events that involved actual or threatened death or 

serious injury, or a threat to the physical integrity of self or 

others. 

(2) 	 The person’s response involved intense fear, helplessness, or 

horror. Note: In children, this may be expressed instead by 

disorganized or agitated behavior. 

B. 	 The traumatic event is persistently reexperienced in one (or more) 

of the following ways: 

(3) 	 Recurrent and intrusive distressing recollections of the event, 

including images, thoughts, or perceptions. Note: In young 

children, repetitive play may occur in which themes or aspects 

of the trauma are expressed. 

(4) 	 Recurrent distressing dreams of the event. Note: In children, 

there may be frightening dreams without recognizable content. 

(5) 	 Acting or feeling as if the traumatic event were recurring 

(includes a sense of reliving the experience; illusions, 

hallucinations, and dissociative flashback episodes, including 

those that occur on awakening or when intoxicated). Note: In 

young children, trauma-specific reenactment may occur. 

(6) 	 Intense psychological distress at exposure to internal or 

external cues that symbolize or resemble an aspect of the 

traumatic event. 

(7) 	 Physiological reactivity on exposure to internal or external 

cues that symbolize or resemble an aspect of the traumatic 

event. 

C. 	 Persistent avoidance of stimuli associated with the trauma and 

numbing of general responsiveness (not present before the trauma), 

as indicated by three (or more) of the following: 

Appendix E: DSM-IV-TR Criteria for Posttraumatic Stress Disorder 311 
(8) 	 Efforts to avoid thoughts, feelings, 

or conversations associated with the 

trauma 

(9) 	 Efforts to avoid activities, places, or 

people that arouse recollections of the 

trauma 

(10) Inability to recall an important aspect 

of the trauma 

(11) Markedly diminished interest or 

participation in signifi cant activities 

(12) Feeling of detachment or estrangement 

from others 

(13) Restricted range of affect (e.g., unable 

to have loving feelings) 

(14) Sense of a foreshortened future (e.g., 

does not expect to have a career, 

marriage, children, or a normal 

lifespan) 

D. 	 Persistent symptoms of increased arousal 

(not present before the trauma), as 

indicated by two (or more) of the following: 

(1) Difficulty falling or staying asleep 

((2) Irritability or outbursts of anger 

(3) 	Diffi culty concentrating 

(4) 	Hypervigilance 

(5) 	 Exaggerated startle response 

E. 	 Duration of the disturbance (symptoms in 

Criteria B, C, and D) is more than 1 month. 

F.	 The disturbance causes clinically 

significant distress or impairment in social, 

occupational, or other important areas of 

functioning. 

Specify if: 

Acute: if duration of symptoms is less than 3 

months 

Chronic: if duration of symptoms is 3 months or 

more 

Specify if: 

With Delayed Onset: if onset of symptoms is at 

least 6 months after the stressor. 

312 Appendix E: DSM-IV-TR Criteria for Posttraumatic Stress Disorder 
Appendix F: Integration 

Self-Assessment for 

Providers 

The Women Embracing Life and Living (WELL) Toolkit is designed to 

help organizations develop plans to improve the quality of care offered to 

women with co-occurring substance abuse and mental health diffi culties 

and histories of experiencing violence. The toolkit includes 

• 	Instructions for using the WELL Toolkit 

• 	Principles for the Trauma-Informed Treatment of Women with Cooccurring Mental Health and Substance Abuse Disorders (WELL 

Project 1999) 

• 	 Self-Assessment for Providers 

• 	 Organizational Self-Assessment 

• 	WELL Planning Tool 

• 	Example of the use of the WELL Planning Tool 

The assessment instruments can be used to take an initial measure 

of an organization’s strengths and weaknesses, and to track progress 

in moving in the desired direction. Organizations that provide direct 

services to families should use the Self-Assessment for Providers, 

while State agencies and funding or regulatory agencies should use the 

Organizational/Agency Self-Assessment. The information from the SelfAssessment can be used in conjunction with the Planning Tool to develop 

concrete plans to strengthen quality of service in particular areas. 

There are many ways of using the Self-Assessment for Providers, 

depending on the priorities of the organization. The general approach is 

to 

1. Look at one subscale at a time. 

2. List the items on which you are not satisfied with your scores. 

3. Prioritize them in terms of importance to your agency. 

4. Choose a certain target number of items. 

5. Develop remedies, steps, and timelines for those items. 

Appendix F: Integration Self- Assessment for Providers 313 
 

 

 

An organization can prioritize the subscales and 

work on only one at a time, or can select items 

from a number of subscales and then prioritize 

the items, without reference to subscale. It is a 

good idea to re-administer the assessment tool 

on a yearly basis in order to track progress. This 

assessment should be done for each program 

administered by your organization. Following is 

the Self-Assessment for Providers. 

Items to be scored on the following Likert Scale: 

1. Rarely 2. Occasionally 3. Sometimes 

4. Often 5. Consistently 

Integration—General 

1. 	 ___ Staff is knowledgeable about the way 

trauma, substance abuse, and mental illness 

interact. 

2. 	 ___ Consumers are provided with psychoeducation about the ways in which trauma, 

substance abuse, and mental illness interact. 

3. 	 ___ Service plans address substance abuse, 

mental illness, and trauma when appropriate. 

4. 	 ___ Case management is available which 

integrates substance abuse, mental health, 

and violence/trauma services. 

5. 	 ___ Multidisciplinary teams can be consulted 

to address service plan diffi culties. 

6. 	 ___ Policies and procedures encourage 

direct care providers to have regular contact 

(with consent of the consumer) with other 

service providers who serve the same client. 

6. 	 ___ Aftercare plans address substance 

abuse, mental illness, and trauma. 

7. 	 ___ The program appropriately supports 

direct care staff in participating in supervision and obtaining training. 

 ___Total 

Trauma Integrated Into 

Other Services 

7. 	 ___ Staff is knowledgeable about symptoms 

of trauma. 

8. 	 ___ Staff is knowledgeable about domestic 

violence. 

9. 	 ___ Staff is knowledgeable about the risk for 

retraumatization of victims of violence by 

staff and peers. 

10. ___ Staff is knowledgeable about vicarious 

traumatization and self-care. 

11. ___ Staff is knowledgeable of nonviolent deescalation techniques. 

12. ___ Consumers are assessed regarding their 

history of experiencing violence. 

13. ___ Consumers are assessed regarding their 

current safety from perpetrators. 

14. ___ Consumers are assessed regarding the 

safety of their current living situation. 

15. ___ Psychoeducation is provided for consumers about domestic violence. 

16. ___ Psychoeducation is provided for consumers about the symptoms of trauma. 

17. ___ Psychoeducation is provided for consumers regarding skills for dealing with 

trauma symptoms such as grounding and 

self-soothing. 

18. ___ Consumers have access to services for 

healing from trauma. 

19. ___ Consumers have access to safety planning. 

20. ___ Consumers have access to legal services. 

21. ___ Crisis Prevention Plans are developed 

in which consumers and providers agree 

regarding what to do if the behavior of the 

consumer begins to escalate. 

22. ___ Advanced Directives are developed 

regarding what consumers would like providers to do in the event of a crisis (i.e., 

who should be notified, where she might be 

transferred if necessary). 

23. ___ Physical restraints are used only as an 

extreme exception and last resort in accordance with the recommendations of the 

report of the Massachusetts Department of 

Mental Health task force on the restraint 

and seclusion of persons who have been 

physically or sexually abused. 

314 Appendix F: Integration Self- Assessment for Providers 
 

24. ___ Consumers are instructed in procedures 

for maintaining each other’s confi dentiality 

in order to maintain safety. 

25. ___ Procedures are in place to protect both 

staff and clients if a perpetrator attempts to 

enter. 

26. ___ A “quick response” agreement is in 

place with local law enforcement should a 

perpetrator attempt to enter the program. 

27. ___ Procedures are in place (which protect 

the confidentiality of current consumers) 

for screening new admissions to determine 

whether they are victimizers of current consumers. 

28. ___ A policy is in place to deny admission to 

the victimizers of a current consumer and 

refer elsewhere (including certifi ed batterers 

intervention). 

29. ___ Procedures are in place to assist a consumer in accessing a corresponding level of 

care in another community if it is not safe 

for her to use the services in her local area. 

30. ___ Consumers are helped to grieve the loss 

of family when it is necessary in order to 

maintain safety. 

31. ___ There is no arbitrary exclusion based on 

domestic violence. 

32. ___ Linkages exist with domestic violence 

providers for referral purposes. 

33. ___ Linkages exist with domestic violence 

providers for consultation purposes.

 ___Total 

Substance Abuse 

Treatment Integrated Into 

Other Services 

34.___ Staff has basic knowledge about substance abuse. 

35.___ Psychoeducation is provided for consumers about substance abuse. 

36.___ Consumers are assessed for substance 

abuse. 

37.___ Linkages exist with substance abuse providers for referral purposes. 

38.___ Linkages exist with methadone providers 

for referral purposes. 

39.___ Linkages exist with substance abuse providers for consultation purposes. 

40.___ Consumers can participate in the program if they are on methadone. 

41.___ There is no arbitrary exclusion based on 

substance abuse. ___Total 

Mental Health Integrated 

Into Other Services 

42.___ Staff has basic knowledge about mental 

disorders. 

43.___ Consumers are assessed for mental 

health problems. 

44.___ Linkages exist with mental health providers for referral purposes. 

45.___ Linkages exist with mental health providers for consultation purposes. 

46.___ Staff has basic knowledge about common 

side effects of psychotropic medications. 

47.___ Psychoeducation is provided for consumers regarding mental disorders. 

48.___ Policies are in place and provided for 

consumers regarding what to do if a consumer decompensates psychiatrically. 

49.___ Referrals are made for psychotropic 

medication evaluation and monitoring. 

50.___ Consumers can participate in the program if they are taking psychotropic medication. 

51.___ There is no arbitrary exclusion based on 

mental health diagnosis or symptoms.

 ___Total 

Empowerment 

52.___ Staff is knowledgeable about informed 

consent and confi dentiality. 

53.___ Staff is knowledgeable about stigmas. 

54.___ Staff has received training in empowerment-based treatment. 

55.___ Intake assessments include the strengths 

of consumers. 

56.___ Consumers are given choices regarding 

which services they access. 

57.___ Consumers may change individual providers of services if they are not satisfi ed. 

Appendix F: Integration Self- Assessment for Providers 315 
58.___ Service plans are individualized. 

59.___ Advanced Directives are developed in 

which consumers indicate what they would 

like providers to do in the event of a crisis 

(i.e., whom to notify, where she would like to 

be transferred to). 

60.___ The program meets the Federal guidelines for confidentiality that apply to substance abuse. 

61.___ The program meets State confi dentiality statutes regarding domestic violence and 

substance abuse counselors. 

62.___ Limits on confidentiality, how records 

are kept, who has access to information, and 

how information could be used to the consumer’s detriment are carefully explained to 

consumers before information is collected. 

63.___ All discussions of consumer information 

are done in private settings. 

64.___ Policies and procedures are in place for 

collecting information from diverse groups 

of consumers about quality of services and 

for incorporating that feedback into service 

planning. 

65.___ Staff and Board members across the 

hierarchy of positions include signifi cant 

numbers of diverse consumers. 

66.___ There is appropriate support for consumers moving into a professional role, such 

as peer leadership training, mentoring, and 

opportunities to function in an advocacy 

role. 

67.___ All consumers have access to peer support.

 ___Total 

Gender Specifi c 

68.___ Staff is knowledgeable about the specifi c 

needs of women. 

69.___ Gender-specific services are provided. 

70.___ Female consumers can work with female 

providers if that is their preference. 

71.___ Female role models in positions of leadership are available.

 ___Total 

Family Focus 

72.___ Psychoeducation is provided for consumers on the intergenerational transmission of 

substance abuse, mental illness, and violence. 

73.___ When a consumer requests services, 

information is collected regarding her children. 

74.___ When a consumer requests services, 

information is collected regarding her children’s need for services. 

75.___ There is a means in place for screening 

children of consumers regarding their need 

for services. 

76.___ Linkages are in place for helping a consumer obtain appropriate services for her 

children. 

77.___ Linkages are in place for helping a consumer obtain appropriate services for other 

family members. 

78.___ In a residential program, there is someone who can assist a consumer in arranging for education of children while she is a 

resident. 

79.___ The program provides a level of parenting education that is appropriate to the level 

of care (a minimal level being assistance and 

education regarding communication with 

children about substance abuse, mental illness, and violence). 

80.___ Child care is provided or there is someone who can help a consumer arrange child 

care that may be necessary for a consumer 

to receive services. 

81.___ Education is provided for a consumer’s 

family (as defined by the consumer) or support system (excluding unsafe relationships). 

316 Appendix F: Integration Self- Assessment for Providers 
 

82.___ Providers work with consumers in 

advance to develop plans for their children 

that would be followed in the event that the 

consumer must be transferred to a more 

acute level of care.

 ___Total 

Cultural Competence 

83.___ Staff is knowledgeable about cultural 

competence. 

84.___ Staff is knowledgeable about the cultures 

represented by the consumers served. 

85.___ Information is collected regarding a consumer’s primary language at intake. 

86.___ Information is collected regarding a 

consumer’s sexual orientation and identity 

at intake. 

87.___ When a consumer requests services, information is collected regarding her cultural/ 

ethnic/racial identity. 

88.___ Differences, including those attributable 

to class, income, culture, race, ethnicity, 

disability, language, sexual orientation, religion, and age are incorporated into service 

planning. 

89.___ Language in all intake and training materials is gender neutral and nonviolent. 

90.___ Services are available in all languages 

that are the first language of a large number 

of the population served. 

91.___ Professional translators are provided 

when necessary, rather than using persons 

with a personal relationship with the consumer. 

92.___ Policies and resources are in place for referring to or obtaining services for consumers who speak languages other than those in 

which the program provides services. 

93.___ There are staff members with the same 

cultural, racial, and ethnic backgrounds as 

the consumers being served. 

94.___ Policies are in place that state that racism, sexism, homophobia, ageism, and other 

forms of hatred will not be tolerated.

 ___Total 

Holistic 

95.___ Information is collected regarding a consumer’s current support system at intake. 

96.___ Information is collected regarding a consumer’s medical status at intake. 

97.___ Information is collected regarding a consumer’s legal status at intake. 

98.___ Information is collected regarding a consumer’s housing status at intake. 

99.___ Information is collected regarding a consumer’s financial status at intake. 

100.___ Psychoeducation is provided for consumers regarding sexually transmitted diseases/ 

HIV/AIDS/Hepatitis C. 

___Total 

Total scores: 

# of 1s—Rarely ___ 

# of 2s—Occasionally ___ 

# of 3s—Sometimes ___ 

# of 4s—Often ___ 

# of 5s—Consistently ___ 

Source: WELL Project, Institute for Health and 

Recovery 2002. For more information about 

the toolkit contact The Institute for Health and 

Recovery, (617) 661-3991, or 

http://www.healthrecovery.org. 

Appendix F: Integration Self- Assessment for Providers 317 
Appendix G: Resource 

Panel Members 

Ana Anders, LICSW 

Senior Advisor 

Special Populations Offi ce 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, Maryland 

Nancy Bateman, LCSW-C, CAC 

Senior Staff Associate 

Division of Professional Development and Advocacy 

National Association of Social Workers 

Washington, D.C. 

Duchy Brecht-Trachtenberg, LCSW-C 

Jutta H. Butler, B.S.N., M.S. 

Public Health Advisor 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Colevia Carter 

Program Offi cer 

Women’s Program 

District of Columbia Department of Health 

Washington, D.C. 

Appendix G: Resource Panel Members 319 
Teresa Chapa, Ph.D. 

Senior Social Science Analyst 

Center for Mental Health Services 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

H. Westley Clark, M.D., J.D., M.P.H., CAS, 

FASAM 

Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Christina Currier 

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Dorynne Czechowicz, M.D. 

Medical Offi cer 

Treatment Development Branch 

Division of Treatment Research and 

Development 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, Maryland 

Sandra Dodge, CNP 

Women’s Health Coordinator 

Nursing Division 

Indian Health Service 

Rockville, Maryland 

Marlene EchoHawk, Ph.D. 

Health Science Administrator 

Division of Behavioral Health 

Indian Health Service 

Rockville, Maryland 

Isabel Ellis, M.S.W. 

Public Health Analyst 

National Institute on Alcohol Abuse and 

Alcoholism 

National Institutes of Health 

Rockville, Maryland 

Krista Evans 

Coordinator 

Women’s Program 

Office of Women’s Programs 

District of Columbia Department of Health 

Washington, D.C. 

Jennifer Fiedelholtz 

Public Health Analyst 

Office of Policy and Program Coordination 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Loretta P. Finnegan, M.D. 

Medical Advisor for the Director 

Office of the Director 

Office of Research on Women’s Health 

National Institutes of Health 

Bethesda, Maryland 

Bettie Foley, M.S., CMAC 

Associate Director 

National Association of Addiction Treatment 

Providers 

Chicago, Illinois 

Jennifer Godfrey 

Intern 

Maternal and Child Health Bureau 

Health Resources and Services Administration 

Rockville, Maryland 

Kathrine Hollinger, D.V.M., M.P.H. 

Health Program Coordinator 

Office of Women’s Health 

Food and Drug Administration 

Rockville, Maryland 

Sharon L. Holmes 

Director 

Office of Equal Employment Opportunity 

and Civil Rights 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

320 Appendix G: Resource Panel Members 
Leah Holmes-Bonilla 

National Mental Health Association 

Alexandria, Virginia 

Arthur MacNeill Horton, Ed.D., ABPN, APP 

Office of the Director 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Ellen Hutchins, M.S.W., M.P.H. 

Social Work Consultant 

Maternal and Child Health Bureau 

Health Resources and Services Administration 

Rockville, Maryland 

Gwendolyn P. Kieta, Ph.D. 

Director 

Women’s Programs Offi ce 

American Psychological Association 

Washington, D.C. 

Lisa King 

Women’s Health Specialist 

Maternal and Child Health Bureau 

Health Resources and Services Administration 

Rockville, Maryland 

Sheila P. Litzky, M.A. 

Statewide Coordinator for Women’s Services 

Alcohol and Drug Abuse Administration 

Spring Grove Hospital Center 

Catonsville, Maryland 

James J. Manlandro, D.O., FAOAAM, FACOFP 

Medical Director 

Family Addiction Treatment Services, Inc. 

Rio Grande, New Jersey 

Carmen Martinez 

Manager 

Office of Equal Employment Opportunity and 

Civil Rights 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Ann Maskell 

Offi ce Manager 

Family Addiction Treatment Services, Inc. 

Dennisville, New Jersey 

Alixe McNeill 

Assistant Vice President 

The National Council on the Aging 

Washington, D.C. 

Kathleen Mitchell 

Program Director 

National Organization on Fetal Alcohol 

Syndrome 

Washington, D.C. 

Susana Perry 

Office of State and Community Programs 

Administration on Aging 

United States Department of Health and Human 

Services 

Washington, D.C. 

Melissa V. Rael, USPHS 

Senior Program Management Offi cer 

Co-occurring and Homeless Branch 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Rosa M. Reyes 

Intern 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Gwen Rubinstein, M.P.H. 

Director of Policy Research 

Legal Action Center 

Washington, D.C. 

Appendix G: Resource Panel Members 321 
Hector Sanchez, M.S.W. 

Team Leader 

Performance Partnership Grant Branch 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Steven J. Shapiro, M.C.J. 

Public Health Advisor 

Division of Practice and Systems Development 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

June Susan Sivilli 

Senior Policy Analyst 

Office of National Drug Control Policy 

Executive Office of the President 

Washington, D.C. 

Lany Sivongsay 

Intern 

Office of Policy Coordination and Planning 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Arlene Stanton, Ph.D., NCC 

Social Science Analyst 

Office of Evaluation, Scientific Analysis and 

Synthesis 

Data Infrastructure Branch 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Richard T. Suchinsky, M.D. 


Associate Chief for Addictive Disorders and 


Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences Services 

Department of Veterans Affairs 

Washington, D.C. 

322 Appendix G: Resource Panel Members 
Appendix H: 

Cultural Competency 

and Diversity Network 

Participants 

Jacqueline P. Butler, M.S.W., CCDC, LISW 

Professor of Clinical Psychiatry 

College of Medicine 

Substance Abuse Division 

University of Cincinnati 

Cincinnati, Ohio 

African American Workgroup 

Deion Cash 

Executive Director 

Community Treatment & Correction 

Center, Inc. 

Canton, Ohio 

African American Workgroup 

Carol S. D’Agostino, C.S.W., CASAC 

Director 

Geriatric Addictions Program 

LIFESPAN of Greater Rochester, Inc. 

Rochester, New York 

Aging Workgroup 

Marty Estrada 

Regional Administrator 

Correctional Treatment 

Florida Addictions and Correctional 

Treatment Services, Inc. 

Tallahassee, Florida 

Hispanic/Latino Workgroup 

Appendix H: Cultural Competency and Diversity Network Participants 323 
Nancy Ferreyra 

Executive Director 

Pacific Research and Training Alliance 

Berkeley, California 

Disabilities Workgroup 

Tonda L. Hughes, Ph.D., R.N. 

Associate Professor 

College of Nursing 

University of Illinois at Chicago 

Chicago, Illinois 

LGBT Workgroup 

Ting-Fun May Lai, M.S.W., CASAC 

Director 

Asian American Recovery Services, Inc. 

New York, New York 

Disabilities/Asian Workgroup 

Lorene Lake, M.A., Ed. 

Executive Director 

Chrysalis House, Inc. 

Crownsville, Maryland 

African American Workgroup 

Rachelle A. Martin 

Provider Relations Manager 

Alcohol, Drug and Mental Health 

Board of Franklin County 

Columbus, Ohio 

African American Workgroup 

Alixe McNeill 

Assistant Vice President 

The National Council on the Aging 

Washington, D.C. 

Aging Workgroup 

Valerie Robinson, M.S., LPC 

Director of Training 

Danya Institute, Inc. 

Central East Addictions Technology Transfer 

Center 

Silver Spring, Maryland 

African American Workgroup 

Hector Sanchez, M.S.W. 

Team Leader 

Performance Partnership Grant Branch 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Hispanic/Latino Workgroup 

Richard T. Suchinsky, M.D.
 

Associate Chief for Addictive Disorders and 


Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences Services 

Department of Veterans Affairs 

Washington, D.C. 

Disabilities Workgroup 

324 Appendix H: Cultural Competency and Diversity Network Participants 
Appendix I: 

Field Reviewers 

Sharon K. Amatetti, M.P.H. 

Sr. Public Health Analyst 

Office of Program Analysis and Coordination 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration 

Rockville, Maryland 

Duiona R. Baker, M.P.H. 

Associate Administrator for Women’s Services 

Substance Abuse and Mental Health Services Administration 

Rockville, Maryland 

Peggy Bean 

Analyst 

Perinatal Substance Abuse 

California Department of Alcohol and Drug Programs 

Sacramento, California 

Faye Belgrave, Ph.D. 

Professor of Psychology 

Department of Psychology 

Virginia Commonwealth University 

Richmond, Virginia 

Mary R. Boyd, Ph.D., R.N. 

Associate Professor 

College of Nursing 

University of South Carolina 

Columbia, South Carolina 

Appendix I: Field Reviewers 325 
Suzette E. Brann, J.D., M.B.A. 

President 

Unlimited Horizons, LLC 

Port Tobacco, Maryland 

Catherine J. Brow 

Specialized Female Services Coordinator 

Commission on Alcohol and Drug Abuse 

Austin, Texas 

Jutta H. Butler, B.S.N., M.S. 

Public Health Advisor 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Donna L. Caldwell, Ph.D. 

Director of Evaluation and Research 

National Perinatal Information Center 

Providence, Rhode Island 

Sherry Dyche Ceperich 

Assistant Professor 

Division of Addiction Psychiatry 

Virginia Commonwealth University 

Richmond, Virginia 

Redonna K. Chandler, Ph.D. 

Health Scientist Administrator 

Services Research Branch 

Division of Epidemiology, Services, and 

Prevention Research 

National Institute on Drug Abuse 

Bethesda, Maryland 

Charlotte Chapman, M.S., LPC, CAC 

Training Director 

Division of Addiction Psychiatry 

Mid-Atlantic Addiction Technology Transfer 

Center 

Virginia Commonwealth University 

Richmond, Virginia 

Kaye Chavis 

Treatment Consultant 

Public Health Programs Director 

Bureau of Alcohol and Drug Abuse Services 

Tennessee Department of Health 

Nashville, Tennessee 

Stephanie S. Covington, Ph.D., LCSW 

Co-Director 

Center for Gender and Justice 

Institute for Relational Development 

La Jolla, California 

Margaret A. Cramer, Ph.D. 

Clinical Psychologist/Instructor 

Harvard Medical School 

Boston, Massachusetts 

A. Rebecca Crowell, LCDC, LPC 

Executive Director 

Nexus Recovery Center 

Dallas, Texas 

Carol S. D’Agostino, C.S.W., CASAC 

Director 

Geriatric Addictions Program 

LIFESPAN of Greater Rochester, Inc. 

Rochester, New York 

Sharon DeEsch, M.A., MAC, LCDC 

Genesis Counseling Associates, P.C. 

Dallas, Texas 

Herman Diesenhaus 

Social Science Analyst 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Marlene EchoHawk, Ph.D. 

Health Science Administrator 

Division of Behavioral Health 

Indian Health Service 

Rockville, Maryland 

Darcy Edwards, Ph.D., M.S.W., CADC I 

Alcohol and Drug/HIV Services Manager 

Counseling and Treatment Services 

Oregon Department of Corrections 

Salem, Oregon 

326 Appendix I: Field Reviewers 
Saul Feldman, Ph.D. 

Chairman & C.E.O. 

United Behavioral Health 

San Francisco, California 

Nancy Ferreyra 

Executive Director 

Pacific Research and Training Alliance 

Berkeley, California 

Norma B. Finkelstein, Ph.D., M.S.W. 

Executive Director 

Institute for Health & Recovery 

Cambridge, Massachusetts 

Jo Ann Ford, M.A. 

Assistant Director 

Substance Abuse Resources and Disability 

Issues School of Medicine 

Wright State University 

Dayton, Ohio 

Joanne Gampel 

Social Science Analyst 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Mary M. Gillespie, Psy.D., CASAC 

Psychologist 

Hudson Valley Community College 

Private Practice 

Saratoga Springs, New York 

Jennifer Glover, M.S., LPC 

Programs Field Representative 

Oklahoma Department of Mental Health and 

Substance Abuse Services 

Oklahoma City, Oklahoma 

Valerie A. Gruber, Ph.D., M.P.H. 

Assistant Clinical Professor 

University of California 

Senior Psychologist Division of Substance Abuse 

and Addiction Medicine 

San Francisco General Hospital 

San Francisco, California 

Joanne M. Hall, Ph.D., R.N. 

Associate Professor 

College of Nursing 

University of Tennessee 

Knoxville, Tennessee 

Deborah Hollis, M.A. 

Director 

Division of Substance Abuse Quality and 

Planning 

Michigan Department of Community Health 

Lansing, Michigan 

Kathryn S. Icenhower, Ph.D., LCSW 

Executive Director 

SHIELDS for Families Project, Inc. 

Los Angeles, California 

Lauren Jansson, M.D. 

Director of Pediatrics 

Center for Addiction and Pregnancy 

Johns Hopkins Bayview Medical Center 

Baltimore, Maryland 

Hendree E. Jones, Ph.D. 

Assistant Professor 

CAP Research Director 

Department of Psychiatry and Behavioral 

Sciences 

Johns Hopkins University Center 

Baltimore, Maryland 

Karol A. Kaltenbach, Ph.D. 

Director/Clinical Associate 

Professor of Pediatrics-Psychiatry and Human 

Behavior 

Maternal Addiction: Treatment Education 

Jefferson Medical College 

Thomas Jefferson University 

Philadelphia, Pennsylvania 

George Kanuck, D.N.Sc. 

Public Health Analyst 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Appendix I: Field Reviewers 327 
Cheryl Ann Kennedy, M.S.W. 

Assistant Director 

Institute for Health & Recovery 

Cambridge, Massachusetts 

Nancy Kennedy, Dr.P.H. 

Scientific Advisor to the Director 

Center for Substance Abuse Prevention 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Mary V. Ker, Ph.D. 


Executive Director 


Optimal Research and Evaluation 


Tucson, Arizona
 

Michael Warren Kirby, Jr., Ph.D., M.A., 


CAC III 


Chief Executive Offi cer 


Arapahoe House, Inc. 


Thornton, Colorado
 

Danica Kalling Knight, Ph.D. 


Research Scientist 


Institute of Behavioral Research 


Texas Christian University 


Fort Worth, Texas
 

Hillary Kunins, M.D., M.P.H. 


Medical Director, HUB II Clinic Program 


Coordinator 

Division of Substance Abuse 

Albert Einstein College of Medicine 

Bronx, New York 

Carol L. Kuprevich, M.A. 

Training Education Administrator 

Division of Alcoholism, Drug Abuse and Mental 

Health 

Delaware Health and Social Services 

New Castle, Delaware 

Martha Kurgans, M.A. 


Women’s Services Program Specialist 


Virginia Department of Mental Health, 


Mental Retardation and Substance Abuse 


Services 

Richmond, Virginia 

Linda Christina Latta, Ph.D. 

Women’s Treatment Coordinator 

Chemical Dependency Bureau 

Montana State Department of Public Health 

and Human Services 

Helena, Montana 

Kayla Mary Leopold, LCSW 

Site Manager 

New Directions Family Treatment Center 

CODA, Inc. 

Portland, Oregon 

Helen J. Levine, Ph.D. 

Senior Research Scientist 

JSI Research and Training 

Boston, Massachusetts 

Kimberly A. Lucas 

Treatment Specialist 

Women’s Treatment Coordinator 

Delaware Division of Substance Abuse and 

Mental Health 

New Castle, Delaware 

Ruby J. Martinez, Ph.D., R.N., CS 

Assistant Professor 

School of Nursing 

University of Colorado 

Denver, Colorado 

Kathleen B. Masis, M.D. 

Medical Officer for Behavioral Health 

Billings Area Indian Health Service 

Billings, Montana 

Lisa A. Melchior, Ph.D. 

Vice President 

The Measurement Group, LLC 

Culver City, California 

Juana Mora, Ph.D. 

Professor 

Northridge Chicano/a Studies Department 

California State University 

Northridge, California 

328 Appendix I: Field Reviewers 
Ruby Neville 

Public Health Advisor 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Joanne Nicholson, Ph.D. 

Associate Professor 

Psychiatry and Family Medicine 

University of Massachusetts Medical School 

Worcester, Massachusetts 

Nancy Nikkinnen, M.D. 

Medical Director 

Children and Parents Program 

Penn-Silver Health Center 

Prince George’s County Health Department 

Forestville, Maryland 

William (Bill) Francis Northey, Jr., Ph.D. 

Research Specialist 

American Association for Marriage and Family 

Therapy 

Alexandria, Virginia 

Gwen M. Olitsky, M.S. 


Founder and C.E.O. 


The Self-Help Institute for Training and 


Therapy 

Lansdale, Pennsylvania 

Dorothy Payne, M.B.A. 


AOD Program Consultant 


Alcohol and Drug Abuse Prevention 


Arkansas Department of Health 


Freeway Medical Center 


Little Rock, Arkansas
 

Thomas A. Peltz, LMHC, CAS, M.Ed. 


Therapist 


Private Practice 


Beverly Farms, Massachusetts
 

David J. Powell, Ph.D. 


President 


International Center for Health Concerns, Inc. 


East Granby, Connecticut
 

Beverly A. Pringle, Ph.D. 

Health Scientist Administrator 

National Institute on Drug Abuse 

Bethesda, Maryland 

Melissa Rael, CAPT., USPHS 

Senior Program Management Offi cer 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Barbara E. Ramlow 


Acting Director 


Institute on Women and Substance Abuse 


University of Kentucky 


Lexington, Kentucky
 

José Rivera, J.D.
 

President
 

Rivera, Sierra and Company, Inc.
 

Brooklyn, New York
 

Valerie Robinson, M.S., LPC 


Director of Training 


Danya Institute, Inc. 


Silver Spring, Maryland
 

Maurilia Rodriguez, Ph.D., R.N., CDE 


Diabetes Consultant 


Houston, Texas
 

Laurie Roehrich, Ph.D. 


Associate Professor 


Department of Psychology 


Indiana University of Pennsylvania 


Indiana, Pennsylvania
 

James Rowan, M.A., CAC III 


Program Manager 


Case Management and Offender Services 


Arapahoe House, Inc. 


Thornton, Colorado
 

Paula G. Ruane 


Marketing Director 


Gaudenzia, Inc. 


Harrisburg, Pennsylvania
 

Appendix I: Field Reviewers 329 
Judith Rubin 

Instructor 

School of Social Work 

San Francisco State University 

San Francisco, California 

Suzanne A. Rymer 

Director 

Health and Social Work Services 

Mature Services, Inc. 

Akron, Ohio 

JoAnn Y. Sacks, Ph.D. 

Principal Investigator 

National Development and Research 

Institutes, Inc. 

New York, New York 

Andrea Savage, Ph.D. 

Associate Professor 

School of Social Work 

Hunter College 

New York, New York 

Karen Saylors, Ph.D. 

Director of Research and Evaluation 

Family and Child Guidance Clinic 

Native American Health Center 

Oakland, California 

Sheryl A. Schrepf, M.S.W. 

Consultant 

Nebraska Coalition for Women’s Treatment 

Lincoln, Nebraska 

Meri Shadley, Ph.D., M.F.T., LADC 

Associate Professor 

Center for the Application of Substance Abuse 

Technologies 

College of Education 

University of Nevada, Reno 

Reno, Nevada 

David E. Smith, M.D. 


Founder and President 


Haight Ashbury Free Clinics, Inc. 


San Francisco, California
 

Diane Batt Smith, LADC 

Substance Abuse Program Coordinator 

Division of Alcohol and Drug Abuse 

Vermont Department of Health 

Burlington, Vermont 

Virginia Steadman 

Director of Women’s Issues 

Alcohol and Substance Abuse Services 

Mississippi Department of Mental Health 

Jackson, Mississippi 

Marceil Ten Eyck, MC 

Psychotherapist/Consultant 

Kirkland, Washington 

Elaine Tophia, M.S.W. 

Executive Director 

National Opioid Treatment Clinician 

Association 

Decatur, Georgia 

Karen Urbany 

Public Health Advisor 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Nancy R. VanDeMark, M.S.W. 

Director 

Research and Program Evaluation 

Arapahoe House, Inc. 

Thornton, Colorado 

Beverly Vayhinger, Ph.D. 

Program Director 

Children and Parents Program 

Prince George’s County Health Department 

Forestville, Maryland 

Suzanne L. Wenzel, Ph.D. 

Senior Behavioral Scientist 

RAND 

Santa Monica, California 

330 Appendix I: Field Reviewers 
Sharon Wilsnack, Ph.D. 

Professor 

School of Medicine & Health Sciences 

Department of Neuroscience 

University of North Dakota 

Grand Forks, North Dakota 

Helen Wolstenholme, M.S.W., LCSW, CCAS 

Women’s Treatment Coordinator 

Substance Abuse Services Section 

North Carolina Division of Mental 

Health/Developmental Disabilities/Substance 

Abuse Services 

Raleigh, North Carolina 

Carolyn A. Work, M.A. 

Training Director 

Institute for Research, Education and Training 

in Addictions 

Pittsburgh, Pennsylvania 

Loretta Young Silvia, M.Ed., Ph.D. 

Associate Professor of Psychiatry 

Department of Psychiatry and Behavioral 

Medicine 

Wake Forest University School of Medicine 

Winston-Salem, North Carolina 

Nancy Young, Ph.D. 

Director 

Children and Family Futures 

Irvine, California 

Shaila Yeh, M.S.W. 

Senior Associate 

Children and Family Futures 

Irvine, California 

Joan E. Zweben, Ph.D. 

Executive Director 

The 14th Street Clinic and Medical Group 

East Bay Community Recovery Project 

University of California 

Berkeley, California 

Janet K. Zwick 

Director 

Division of Health Promotion, Prevention and 

Addictive Behaviors 

Iowa Department of Public Health 

Des Moines, Iowa 

Appendix I: Field Reviewers 331 
Appendix J: 

Acknowledgments 

Numerous people contributed to the development of this TIP, including 

the TIP Consensus Panel (see p. xi), the KAP Expert Panel (see p. 

xv), the Federal Resource Panel, (see appendix G), the KAP Cultural 

Competency and Diversity Network (see appendix H), and TIP Field 

Reviewers (see appendix I). 

In addition, Rose M. Urban, M.S.W., J.D., LCSW, LCAS, served as the 

CDM KAP Executive Deputy Project Director. Roberta Hochberg served 

as the CDM KAP Managing Project Co-Director. Claudia A. Blackburn, 

M.S., Psy.D., served as the CDM KAP Expert Content Director. Other 

CDM KAP personnel included Susan Kimner, Deputy Project Director/ 

Editorial Director; Amy Conklin, Editor; Janet Humphrey, M.A., 

former Editor; Virgie D. Paul, M.L.S., Librarian; Lee Ann Knapp, 

Quality Assurance Editor. 

JBS KAP personnel included Barbara Fink, R.N., M.P.H., KAP 

Managing Project Co-Director; Dennis Burke, M.S., M.A., former 

Product Development Manager; Wendy Caron, Senior QA Editor; Leah 

Bogden, Junior Editor; and Frances Nebesky, Senior QA Editor. 

Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Catalina 

Bartlett, M.A., Randi Henderson, B.A., Susan Hills, Ph.D., Helen Oliff, 

and Mary Lou Rife, Ph.D., were writers. 

Appendix J: Acknowledgments 333 
Index
 

A 

AA. See Alcoholics Anonymous
 

AACP. See American Association of Community 


Psychiatrists
 

Abuse Assessment Screen
 

description and uses, 71
 

Acculturation
 

effect on substance use disorders, 24, 26
 

forced acculturation and deculturalization of Native Americans, 120
 

Hispanic/Latina women and, 106, 107
 

screening and assessment and, 59–60
 

Acculturation Rating Scale for Mexican 


Americans
 

description, 59
 

The Addiction and Trauma Recovery 


Integration Model (Miller and Guidry), 171
 

Addiction Severity Index
 

description and uses, xx, 12, 76, 78–79, 


297
 

Addressing Suicidal Thoughts and Behaviors in 


Substance Abuse Treatment (TIP 50), 68, 78
 

Administrators. See also Advice to Clinicians 

or Administrators; Note(s) to Clinicians or 

Administrators 

consumer direction, participation, and 

empowerment, 187–188
 

creating a healing environment, 188
 

executive summary, xxii–xxiii
 

overview of issues for, 181
 

staffing issues, 188–193
 

strategies for organizational change, 


193–196 

Women Embracing Life and Living 

(WELL) Project Self-Assessment for 

Providers, 313–317 

Adolescents. See also Age factors; Children
 

peer pressure association with initiation of 


drug use, 20
 

physiological effects of substance abuse 


and, 39–40
 

sexual orientation and, 22
 

Treatment of Adolescents with Substance 


Use Disorders, 15
 

Adoption studies
 

genetic risk factors, 19
 

Adverse Childhood Experiences Study
 

description, 154
 

Advice to Clinicians or Administrators at-risk 


screening for drug and alcohol use during 


pregnancy, 66
 

considerations in involving the partner in 


treatment, 146
 

culturally responsive screening and 


assessment, 59
 

description, 15
 

general guidelines for selecting and using 


screening and assessment tools, 76
 

general guidelines of assessment for 


women, 81
 

impact of trauma and prenatal care, 102
 

mental health screening and women, 75
 

postpartum relapse prevention, 186
 

relational model approach to therapy, 144
 

retraumatization, 169
 

substance abuse screening and assessment 


among women, 61
 

substance abuse treatment and African-


American women, 114
 

substance abuse treatment and Asian- and 


Pacific-American women, 116–117
 

substance abuse treatment and Hispanic/
 

Latina women, 106
 

substance abuse treatment and lesbian 


and bisexual women, 125
 

substance abuse treatment and Native-


American women, 121–122
 

substance abuse treatment and older 


women, 129
 

substance abuse treatment and women in 


rural areas, 132
 

substance use and birth outcomes, 50
 

using patterns of use as a clinical guide, 


35–36 

when is a woman ready for trauma 

processing?, 167
 

women with co-occurring disorders, 158
 

women with eating disorders, 177
 

Index 335
 
Advocacy services
 

for children, 291
 

for women, 290
 

African Americans
 

acculturation effect on substance use 


disorders, 24
 

Afrocentric perspective, 112
 

clinical treatment issues, 110–111
 

cognitive-behavioral therapy and, 112–113
 

defi nition, 16
 

demographics, 109
 

family therapy and, 113
 

group therapy and, 112
 

homelessness and, 135
 

lesbian and bisexual women, 126
 

mistrust of treatment services, 85–86
 

misuse of OTC cough and cold medications 


and, 48
 

primary substance of abuse on admission 


to treatment, 32
 

resiliency factors, 113–114
 

spirituality and, 80, 111
 

substance use among, 109–110
 

treatment approaches for, 111
 

women in the criminal justice system and, 


134
 

Afrocentric perspective
 

treatment issues, 112
 

Aftercare. See Continuing care 

Age factors. See also Adolescents; Children; 

Elderly persons; Older women 

alcohol abuse and dependence, 30
 

initiation of use, 18
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug among women aged 18 or older by 


age group: 2003 (fi gure), 32
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug by gender and age, 2006 (fi gure), 


31
 

physiological effects of substance abuse 


and, 39–40
 

treatment retention, 138
 

Alaska-Native population
 

primary substance of abuse on admission 


to treatment, 32
 

tobacco use prevalence, 28
 

Alateen, 153
 

Alati, R.
 

alcohol exposure in utero, 49 

Alcohol 

age factors in vulnerability to effects of, 39–40 

gender differences in metabolism and 


effects, 40–41, 46
 

physiological effects, 40–46
 

Alcohol-related birth defects
 

description, 49
 

Alcohol-related neurodevelopmental disorder
 

description, 49
 

Alcohol use and abuse. See also Substance 


abuse
 

African Americans and, 109–110
 

age factors, 30
 

Asian/Pacific Americans and, 115–116
 

birth outcomes and, 48–49
 

breast and other cancers and, 42
 

cardiovascular disease and, 41
 

depression and, 173
 

Hispanic/Latina population, 104–105
 

HIV/AIDS and, 52–53
 

lesbian and bisexual women and, 124
 

light, moderate, and heavy drinking 


defi nitions, 41
 

liver and other organ damage and, 41
 

Native Americans and, 119
 

neurological effects, 45–46
 

older women and, 127–128, 130
 

osteoporosis and, 42, 45
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug among women aged 18 or older by 


age group: 2003 (fi gure), 32
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug by gender and age, 2006 (fi gure), 


31
 

pregnancy and, 28, 42, 48–49
 

prevalence in women, 26
 

reproductive consequences, 41–42
 

Rural American women and, 131
 

sample client-educating lecture outline 


for counselors physiological effects of 

alcohol, 43–45
 

screening tools, 62–63
 

telescoping phenomenon, xix, 7, 27, 40
 

trauma history and, 155
 

use of illicit drugs, alcohol, and tobacco 


by females aged 12 or older, past year 

336 Index 
and past month, numbers in thousands 


and percentages, 2006 (fi gure), 29
 

withdrawal issues, 66, 97
 

Alcohol Use Disorder Identifi cation Test
 

compared with T-ACE, 64
 

description and uses, 62
 

Alcohol Use During Pregnancy Project
 

description, 65
 

Alcoholics Anonymous
 

description, 186, 275
 

Alkali Lake Band, Canada
 

community-wide sobriety rate, 123
 

Allen Barriers to Treatment Instrument
 

text of, 307–309
 

American Association of Community 


Psychiatrists
 

Level of Care Utilization System for 


Psychiatric and Addiction Services, 68, 


298
 

American Indian population. See also Native 


Americans
 

primary substance of abuse on admission 


to treatment, 32
 

tobacco use prevalence, 28
 

American Psychiatric Association
 

Diagnostic and Statistical manual of 


Mental Disorders, Fourth Edition, Text 


Revision, 16, 70, 154, 159, 161, 275, 


311–312
 

American Society of Addiction Medicine
 

detoxification, Levels I-IV, 96–98
 

early intervention, Level 0.5, 95–96
 

intensive outpatient treatment, Level II, 


99
 

medically managed intensive inpatient 


treatment, Level IV, 102
 

outpatient treatment, Level I, 98–99
 

placement criteria, 82, 83, 95–102
 

residential and inpatient treatment, Level 


III, 99–102
 

Americans with Disabilities Act
 

treatment issues, 87
 

Amphetamines
 

birth outcomes and, 52
 

gender differences in metabolism and 


effects of, 46–47
 

weight management and, 176
 

Anemia
 

alcohol use and, 41
 

Annual Homeless Assessment Report to 


Congress
 

number of Americans experiencing 


homelessness, 135
 

Anorexia nervosa. See also Eating disorders
 

defi nition, 175
 

percent of women with, 174
 

substance use disorders and, 175–176
 

Antidepressants
 

depression treatment, 174
 

Anxiety disorders. See also Posttraumatic stress 


disorder
 

Beck Anxiety Inventory, 68
 

co-occurring substance use, 23, 160–173
 

family ties and, 160
 

general treatment considerations, 160–161
 

most common disorders, 160
 

physical or sexual abuse survivors and, 22
 

postpartum depression and, 158
 

screening instruments, 67–68
 

symptoms of, 160–161
 

Anxiolytics
 

gender differences in metabolism and 


effects of, 47
 

older women and, 128
 

ARBDs. See Alcohol-related birth defects
 

ARND. See Alcohol-related neurodevelopmental 


disorder 

ASAM. See American Society of Addiction 

Medicine 

Ashley, O.S. 

family responsibilities of women, 11
 

ASI. See Addiction Severity Index
 

Asian American Multidimensional Acculturation 


Scale
 

description, 118
 

Asian/Pacifi c Americans
 

barriers to treatment, 118
 

clinical treatment issues, 117–118
 

cultural norms, 115–116
 

demographics, 115
 

depression and, 21
 

ethic of hard work and, 118
 

family defi nition, 117–118
 

“flushing” response to alcohol and, 115
 

growth of population, 115
 

interrelatedness among family, 


community, environment, and the 


spiritual world, 118
 

lesbian and bisexual women, 126
 

Index 337
 
mix-gender treatment groups and, 85 

primary substance of abuse on admission 

to treatment, 32
 

resiliency factors, 118
 

substance abuse among, 115–117
 

tobacco use prevalence, 28
 

Assessment. See also Screening; specifi c 

assessment instruments 

acculturation and language issues, 59–60 

assessment interviews, xix, 75–78 

available screening and assessment tools in 

multiple languages (fi gure), 80
 

of children, 287
 

cognitive and learning disabilities and, 60
 

compared with screening, 58
 

coping skills and, 79
 

definition, xx, 58
 

ethnicity and culture and, 58–60
 

executive summary, xx–xxi
 

factors of infl uence, 58–60
 

as a fluid process, 75
 

health assessment and medical 


examination, 80–81
 

language issues, 59–60, 79
 

overview, 57–58
 

periodic reassessment, 75
 

psychosocial and cultural history, 76–78
 

range of concerns, 285
 

sexual orientation and, 60
 

socioeconomic status and, 60
 

spirituality and religiousness measures, 


79–80
 

strengths and, 79
 

TIPs that provide assessment information 


relevant to women in specifi c settings 

(fi gure), 78
 

tools for substance use disorders, 78–79
 

trauma-informed treatment approach 


and, 166
 

using qualified and trained clinicians for, 


74
 

Women Embracing Life and Living 

(WELL) Project Self-Assessment for 

Providers, 313–317 

Assessment interviews 

Addiction Severity Index, xx, 12, 76, 78–79, 297
 

counselor sensitivity and, 75
 

focus of, 76
 

Psychosocial History assessment tool, 76
 

therapeutic relationship and, 75
 

Assessment tools for substance use disorders 

Addiction Severity Index, xx, 12, 76, 78–79, 297
 

Comprehensive Intake, 78
 

Drinker Inventory of Consequences, 79, 


302–306
 

Intake for Women and Children, 78
 

Texas Christian University Brief Intake, 


78
 

Audience for the TIP, 15
 

AUDIT. See Alcohol Use Disorder Identifi cation 


Test 

B 

Bacterial infections. See also specifi c infections
 

heroin use and, 47
 

substance use disorders and, 7
 

Bagnardi, V.
 

cancer and alcohol use, 42
 

Barriers to treatment engagement
 

Allen Barriers to Treatment Instrument, 


307–309
 

helping women overcome barriers, 89–90
 

interpersonal, 84–85
 

intrapersonal, 84
 

percentages of reasons for not receiving 


substance use treatment in the past 


year among women aged 18-49 who 


needed treatment and who perceived a 


need for it: 2004-2006 (fi gure), 85
 

sociocultural, 84, 85–86
 

structural, 84, 86–87
 

systemic, 84, 87
 

Beck Anxiety Inventory
 

description and uses, 68
 

Beck Depression Inventory-II
 

description and uses, 67
 

Benzodiazepines
 

anxiety disorders and, 161
 

older women and, 128
 

withdrawal from, 66, 97
 

Beyond Trauma: A Healing Journey for Women 


and A Healing Journey: A Workbook for 


Women, 171
 

Bibliography, 197–272 

Binge eating 

defi nition, 174–175 

substance abuse and, 72–73 

Biological and psychological characteristics of 


women
 

co-occurring disorders, 8
 

338 Index 
gynecological issues, 7–8
 

physical responses to substances, 7, 27
 

pregnancy issues, 8
 

susceptibility to serious medical problems 


and disorders, 7
 

trauma and, 8–9
 

Biopsychosocial uniqueness of women
 

biological and psychological characteristics, 7–9
 

developmental characteristics, 13–14
 

social characteristics, 9–13
 

treatment needs and, 6–7
 

Birth outcomes
 

alcohol use and, 48–49
 

amphetamine and methamphetamine use 


and, 52
 

cocaine and, 49–50
 

marijuana use and, 51–52
 

opioid use and, 50–51
 

residential services for pregnant women 


and, 101
 

tobacco use and, 52
 

Bisexual women. See Lesbian and bisexual 


women
 

Black Women’s Health Study
 

perceived experiences of racism and 


breast cancer incidence, 39
 

Blacksin, B.
 

treatment retention factors, 142
 

Bluthenthal, R.N.
 

women of color and treatment retention, 


138
 

Boyd-Franklin, N.
 

spirituality of African Americans, 111
 

Bradley, K.A.
 

CAGE sensitivity, 63
 

osteoporosis and alcohol use, 42
 

Brady, T.M.
 

family responsibilities of women, 11
 

Braided funding
 

defi nition, 293
 

Breast cancer
 

alcohol use and, 42
 

perceived experiences of racism and, 39
 

substance use disorders and, 7, 14
 

Brief Interventions and Brief Therapies for 


Substance Abuse (TIP 34), 96, 143
 

Brief Note(s) to the Clinician
 

description, 15
 

Brief Symptom Inventory
 

description and uses, 67
 

Brindis, C.D
 

function of case management, 91–92
 

Bronfenbrenner, U.
 

ecological model, 2–4
 

Brown, V.
 

components of outreach, 88
 

Bryant, J.
 

partner relationship effect on substance 


use, 27
 

Bulimia nervosa. See also Eating disorders
 

defi nition, 175
 

description, 73
 

general population incidence, 73
 

percent of women with, 174
 

substance use disorders and, 175–176
 

Buprenorphine
 

clinical guidelines for the use of, 98
 

opioid dependence treatment for pregnant 


women, 51
 

C 

CAGE
 

CAGE Questionnaire (fi gure), 62
 

compared with TWEAK, 63
 

description and uses, 62–63, 74
 

gender sensitivity and, 63
 

CAGE-AID
 

description, 63
 

Cancer of the vagina
 

alcohol use and abuse and, 42
 

Cardiovascular disease
 

African Americans and, 111
 

alcohol use and, 40, 41
 

heroin use and, 47
 

substance use disorders and, 7, 14
 

Career issues. See also Employment
 

complexity of women’s work lives, 13
 

Caregiver role
 

as an obstacle to treatment, 84–85
 

issue overview, 11, 14
 

CARF. See Commission on Accreditation of 


Rehabilitation Facilities
 

CASA. See National Center on Addiction and 


Substance Abuse
 

Case management
 

description and uses, 91–92, 285, 287–288
 

trauma-informed treatment approach 


and, 168–169
 

Index 339
 
Caucasian population 

acculturation effect on substance use 

disorders, 24 

misuse of OTC cough and cold medications 

and, 48 

primary substance of abuse on admission 

to treatment, 32 

CBT. See Cognitive-behavioral therapy 

“Celebrating Families”TM, 153 

Center for Epidemiologic Study Depression 

Scale 

description and uses, 67 

Center for Substance Abuse Treatment. See also 

specifi c publications 

comprehensive model of care, 4, 15 

Congress’s funding of, 273 

Residential Women and Children/ 

Pregnant and Postpartum Women 

programs, 100, 273, 281 

Centers for Disease Control and Prevention 

HIV association with injecting drugs, 52 

life expectancy for women, 14 

Cervical cancer 

alcohol use and abuse and, 42 

substance use disorders and, 7 

Chan, C.S. 

Asian/Pacific American lesbian and 

bisexual women, 126 

Chang, G. 

T-ACE compared with MAST and AUDIT, 

64 

The Change Book: A Blueprint of Technology 

Transfer, 194 

Chasnoff, I.J. 

5Ps screening for pregnant women, 65 

Chen, H. 

cirrhosis mortality, 54 

Child care. See also Children 

as an obstacle to treatment, 86 

detoxification issues, 97 

immediate and short-term services, 291 

issue overview, 10–11, 13 

onsite, 141, 288, 290 

outpatient treatment and, 98 

residential treatment programs and, 

100–101 

therapeutic, 288 

women in the criminal justice system and, 

134 

Child custody. See also Children 

African Americans and, 110 

issue overview, 10 

loss of custody as a treatment obstacle, 85, 

87, 88 

mothers in treatment who wish to 

relinquish care, 154 

parent-child visiting and, 153–154 

regaining custody, 153 

women in the criminal justice system and, 

134 

Child protective services 

co-occurrence of a substance use disorder 

and involvement in the child welfare 

system, 87 

reunification of mothers and children 

after treatment, 101 

treatment referral and, 31 

treatment retention and referral to or 

involvement with, 139 

Child welfare system 

confidentiality issues, 87, 88 

linking women with, 289–290 

prevalence of co-occurring disorders 

among women in, 158 

Children. See also Adolescents; Age factors; 

Child care; Child custody; Child welfare 

system; Comprehensive Substance Abuse 

Treatment Model for Women and Their 

Children; Services for children of women in 

substance abuse treatment 

accompanying their mothers in residential 

treatment settings, 86, 100–101, 141 

information about mothers’ substance use 

disorders, 152–153 

physical and sexual abuse by parents, 156 

Children with special needs 

accompanying mothers in residential 

treatment, 154 

assessment of, 154 

Cigarette smoking. See Tobacco use 

Cirrhosis 

African Americans and, 111
 

alcohol use and, 40, 41
 

hepatitis C virus and, 54
 

substance use disorders and, 7
 

CIWA-Ar. See Clinical Institute Withdrawal 

Assessment 

340 Index 
Clinical Activities 

chronological relationship between cooccurring disorders, 25
 

description, 15
 

exploring the history and infl uence of 


relationships: sociogram, 148–149 

helping women overcome barriers to 

treatment, 89–90 

sample client-educating lecture outline 

for counselors physiological effects of 

alcohol, 43–45 

Clinical Guidelines for the Use of 


Buprenorphine in the Treatment of Opioid 


Addiction (TIP 40), 98
 

Clinical Institute Withdrawal Assessment
 

description and uses, 298
 

Clinical support services. See also 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children 

for children, 290–291
 

description, 278
 

elements of (fi gure), 279
 

for women, 288–290
 

Clinical treatment services
 

for children, 281–283, 287–288
 

description, 277–278
 

elements of (fi gure), 277
 

interrelated elements of (fi gure), 284
 

for women, 283–287
 

Co-occurring disorders. See also specifi c 

disorders 

defi nition, 16
 

Hispanic/Latina population and, 108
 

integrated system of care, 157–158
 

issue overview, 8, 157–158
 

mental disorders, 23–24, 158–177
 

need for ongoing evaluation, 157–158
 

physiological effects and consequences of 


substance abuse and, 40
 

pregnancy and, 139, 158, 160
 

sample timeline, 25
 

treatment retention and, 139
 

women in the criminal justice system and, 


134
 

women with disabilities and, 134
 

Cocaine/crack
 

African Americans and, 110
 

Asian/Pacific Americans and, 117
 

birth outcomes and, 49–50
 

gender differences in metabolism and 

effects of, 46
 

Hispanic/Latina population and, 105
 

homelessness and, 135
 

Native Americans and, 120
 

weight management and, 176
 

Cognitive-behavioral therapy
 

African Americans and, 112–113
 

anxiety disorders and, 161
 

depression and, 174
 

eating disorders, 176
 

Eurocentric bias in, 113
 

smoking cessation, 178
 

Cognitive impairment. See also Women with 

disabilities
 

alcohol use and abuse and, 40, 45–46
 

screening and assessment and, 60
 

substance use disorders and, 7
 

Cohen, J.B. 

Counseling Addicted Women: A Practical 


Guide, 147
 

Collaborative approach to therapy
 

treatment retention and, 140
 

Columbia University
 

initiation of substance use among women, 


27
 

Commission on Accreditation of Rehabilitation 


Facilities
 

psychosocial history guidelines, 77
 

Community support services. See also 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children 

continuing care and, 278
 

description, 278–279, 291
 

elements of (fi gure), 280
 

recovery services, 290, 291
 

services included, 291–292
 

Comprehensive Case Management for 


Substance Abuse Treatment (TIP 27), 92
 

Comprehensive Intake
 

description and uses, 78
 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children 

adapting, 294–295 

as an evolving paradigm, 274–277 

background, 273–274 

basket metaphor, 275–277 

clinical support services, 278, 288–291 

clinical treatment services, 277–278, 

283–288 

Index 341
 
community support services, 278–279, 

291–292 

concept of interdependence, 276 

confidentiality and informed consent and, 

275 

description, 4, 15, 84, 100, 102 

funding issues, 292–293, 294 

insights about the needs of women and 

children, 274 

interrelated elements in (figures), 4, 276 

purpose of, 274–275 

services for children of women in 

substance abuse treatment, 279, 281– 

283 

unifi ed fiscal planning concept, 293–294 

Compulsive eating 

substance use disorders and, 72–73, 176 

Confi dentiality 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children and, 

275 

Rural American women and, 131, 133 

treatment engagement and, 87, 88 

Consumer direction, participation, and 

empowerment 

benefits of, 187–188 

Contextual factors 

biopsychosocial uniqueness of women, 

6–13 

creating the context, 1–4 

executive summary, xvii–xviii 

gender responsive treatment principles, 

4–6
 

overview, 1, 4–6
 

sociocultural, 2–4
 

Continuing care 

community support services and, 278–279 

Comprehensive Substance Abuse 

Treatment Model for Women and Their 

Children and, 278–279 

description, 181, 287 

discontinuing treatment during, 181–182 

Coping skills 

assessment and, 79 

as protective factors, 23 

trauma-informed treatment approach 

and, 168 

Corse, S.J. 

residential services for pregnant women, 

101 

Counseling Addicted Women: A Practical Guide 

(Cohen), 147 

Counselors. See also Cultural competence 

assessment interviews and, 75 

characteristics of effective counselors, 

139, 140, 141–142 

client-counselor expectations, 12 

comfort level of the counselor or 

healthcare professional, 61–62 

continuing care services, 181–182 

goals and training guidelines for substance 

abuse treatment counselors (fi gure), 

191–192 

hepatitis C virus counseling, 55 

impact of gender differences in clientcounselor relationships, 141–142 

implications for the male counselor, 141 

recovery management, 181–186 

relapse variables, 181–182, 183–186 

sample client-educating lecture outline 

for counselors physiological effects of 

alcohol, 43–45 

support systems for women, 186 

therapeutic alliance, 75, 88, 141–142 

tolerating or accepting a client’s 

relationships that the counselor fi nds 

objectionable, 145 

training for, 189–190, 193 

trauma-informed treatment approach 

and, 168 

treatment outcomes variables, 182–186 

vicarious traumatization, 192–193 

Women Embracing Life and Living 

(WELL) Project Self-Assessment for 

Providers, 313–317 

Couples therapy 

treatment outcomes and, 138 

Covington, S.S. 

Helping Women Recover: A Program for 

Treating Addiction, 145, 171 

Criminal justice system 

prevalence of co-occurring disorders, 134 

treatment referral and, 31 

treatment retention factors, 138, 139 

women in, 134 

Crisis intervention 

description, 285 

342 Index 
Cultural competence
 

Hispanic/Latina clients and, 107
 

Improving Cultural Competence in 


Substance Abuse Treatment, 32
 

treatment of Native Americans and, 122–
 

123
 

of treatment programs, 86
 

Cultural Competency and Diversity Network 


participants, 323–324
 

Culture. See also Psychosocial and cultural 

history; Racial/ethnic factors; Sociocultural 

context 

acculturation effect on substance use 

disorders, 24, 26
 

cultural relevance and, 58
 

negative attitudes toward substance abuse 


as an obstacle to treatment, 85–86 

physiological effects of substance abuse 

and, 38–39 

screening and assessment and, 58–60 

D 

Danger Assessment
 

description and uses, 71
 

DATOS. See Drug Abuse Treatment Outcome 


Study
 

Day, N.
 

birth outcomes and marijuana use, 52
 

Decategorization
 

defi nition, 293
 

Demographics
 

African Americans, 109
 

Asian/Pacific Americans, 115
 

Hispanic/Latina population, 104
 

lesbian and bisexual women, 123–124
 

Native Americans, 119
 

older women, 127
 

Rural American women, 130–131
 

sociodemographics of treatment retention, 


138
 

Demonstration Grant Program for Residential 


Women and their Children
 

Lessons Learned: Residential Substance 


Abuse Treatment for Women and Their 


Children, 108
 

Depression. See also Postpartum depression
 

co-occurring substance use, 23–24, 173–
 

174
 

description, 173 

factors increasing a women’s chance of 


depression prior to deliver of a baby, 


158, 160
 

hepatitis C virus treatment and, 54
 

older women and, 127
 

physical or sexual abuse survivors and, 22
 

racial/ethnic factors, 21, 173
 

screening instruments, 67–68
 

sexual orientation and, 21
 

substance abuse treatment and, 174
 

Detoxification, ASAM Levels I-IV
 

description, 96, 285
 

length of, 97
 

pregnancy and, 97–98, 151
 

trauma victims and, 97
 

treatment after, 97
 

women with dependent children and, 97
 

Detoxification and Substance Abuse Treatment 

(TIP 45), 78, 96, 98
 

Developmental characteristics of women
 

life-course issues, 13
 

physiological effects of substance abuse 


and, 39–40
 

Developmental services for children, 288
 

Diabetes
 

alcohol consumption and, 40
 

Diagnostic and Statistical manual of Mental 

Disorders, Fourth Edition, Text Revision 

postpartum depression criteria, 159
 

posttraumatic stress disorder symptoms 


and criteria, 70, 161, 311–312
 

substance abuse definition and treatment, 


16, 275
 

Texas Christian University Drug Screen II 


and, 62
 

trauma criteria, 154
 

Dialectical behavior therapy
 

eating disorders, 176
 

Discrimination
 

substance use disorder risk factor, 24
 

Disordered eating
 

defi nition, 175
 

Divorce
 

risk factor for substance use disorders, 


xviii, 19–20
 

Domestic violence. See also Interpersonal 


violence; Trauma
 

substance use disorders and, 23
 

Index 343
 
Drabble, L. 

sexual orientation and substance use, 21
 

DrinC. See Drinker Inventory of Consequences
 

Drinker Inventory of Consequences
 

description and uses, 79
 

text of, 302–306
 

Drug Abuse Treatment Outcome Study
 

age factors in treatment retention, 138
 

Drug use monitoring
 

range of concerns, 287
 

DSM-IV-TR. See Diagnostic and Statistical 

manual of Mental Disorders, Fourth 

Edition, Text Revision 

E 

Early and Periodic Screening, Diagnostic, and 


Treatment
 

description, 294
 

Early intervention, ASAM Level 0.5
 

approaches for, 96
 

motivational interviewing, 96
 

during pregnancy, 96
 

services included, 95
 

treatment goals, 95–96
 

EAT-26. See Eating Attitudes Test-26 

Eating Attitudes Test-26
 

description and uses, 73
 

text of, 299–301
 

Eating disorders. See also specifi c disorders
 

biopsychosocial context, 176
 

co-occurring substance use, 23–24, 175–
 

176
 

compulsive eating, 72–73
 

defi nitions (fi gure), 175
 

difficulty of detecting, 174–175
 

misuse of over-the-counter drugs and, 47
 

mortality rates, 72
 

nutritional counseling and, 177
 

percent of women in substance abuse 


treatment with, 72
 

personality disorders and, 176
 

prevalence of, 174
 

screening for, 72–73
 

treatment for substance use disorders 


and, 176–177 

Economic issues 

overview, 2
 

Ecstasy. See Methylenedioxy-methamphetamine
 

Education. See also Training
 

discrimination and opportunities for, 24
 

in parenting and child development, 289 

remediation and support for women in 

treatment, 289
 

services for children, 291
 

substance abuse education, 285–286, 288
 

trauma-informed treatment approach 


and, 166
 

treatment retention and level of, 138
 

vocational and academic, 292
 

Elderly persons. See also Older women 

physiological effects of substance abuse 

and, 40
 

substance dependence issues, 14
 

women as caregivers for, 14
 

Eliason, M.
 

definitions of “lesbian,” “gay,” and 


“bisexual,” 124
 

Employment. See also Unemployment
 

complexity of women’s work lives, 13
 

discrimination and, 24
 

readiness services, 289
 

support services, 292
 

Endometrial cancer
 

alcohol use and, 42
 

Enhancing Motivation for Change in Substance 


Abuse Treatment (TIP 35), 96, 143
 

EPSDT. See Early and Periodic Screening, 


Diagnostic, and Treatment 

Ethnic factors. See Racial/ethnic factors 

Evans, S.M. 

cocaine effects on menstruation, 46
 

Executive Orders
 

establishment of tribal colleges for Native 


Americans, 123
 

Eyler, F.D.
 

prenatal cocaine exposure effects, 49
 

F 

Faith-based initiatives. See also Religious and 


spiritual practices
 

for early intervention, 96
 

Faith-based organizations. See also Religious 


and spiritual practices
 

support for women, 292
 

Fals-Stewart, W.
 

couples therapy and treatment outcomes, 


138
 

344 Index 
Families
 

family/partner support, 10
 

influence of on treatment, 143–145
 

parental warmth as a protective factor, 20
 

risk factor for substance use disorders, 


xviii, 18–19
 

substance-using families, 143
 

Family therapy
 

African Americans and, 113
 

as an important approach in substance 


abuse treatment for women, 144
 

eating disorders, 176
 

treatment outcomes and, 138
 

FAS. See Fetal alcohol syndrome 

FASDs. See Fetal alcohol spectrum disorders 

Fetal alcohol spectrum disorders 

description, 49
 

Native Americans and, 122
 

Fetal alcohol syndrome
 

description, xix–xx, 49
 

Field reviewers, 325–331
 

Finkelstein, N.
 

barriers to providing resources for 


pregnant women, 86
 

Fitzgerald, L.F.
 

complexity of women’s work lives, 13
 

5Ps screening for pregnant women
 

description and uses, 65
 

questions (fi gure), 65
 

Frank, D.A.
 

prenatal cocaine exposure effects, 49, 50
 

Fried, P.A.
 

birth outcomes and marijuana use, 52
 

Funding issues
 

services for women and children, 292–293
 

G 

Gary, L.E.
 

resiliency factors for African-American 


women, 113–114
 

Gender
 

defi nition, 16
 

Gender factors
 

metabolism and effects of alcohol, 40–41, 


46
 

metabolism and effects of licit and illicit 


drugs, 46–48
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug by gender and age, 2006 (fi gure), 

31
 

relapse, 183
 

substance use by the Hispanic/Latina 


population, 105–106
 

treatment outcomes, 182
 

in treatment retention, 138
 

Gender gap
 

prevalence of substance use and, 27, 30
 

Gender responsive
 

defi nition, 16
 

Gender-Responsive Strategies: Research, 


Practice, and Guiding Principles for Women 


Offenders, 134
 

Gender responsive treatment
 

elements and principles of, xviii, xxiii, 


4–6, 15
 

overview, 4–6
 

strategies for organizational change, 


193–196
 

General Health Questionnaire
 

description and uses, 67
 

Genetic factors
 

depression, 173
 

“flushing” response to alcohol, 115
 

rates of diseases among African 


Americans, 109
 

risk for adult children of parents who 


abuse alcohol, 18–19
 

Greenfield, S.F. [correct initial?]
 

women-specific relapse prevention groups, 


183–184
 

Grella, C.E.
 

levels of distress in women, 182
 

pregnancy and treatment retention, 139
 

Grosenick, J.K.
 

counselor gender impact on treatment 


retention, 142
 

Gross, M.
 

components of outreach, 88
 

Group therapy
 

African Americans and, 112
 

eating disorders, 176
 

female-only therapy groups, 140–141
 

promising practices and strategies for 


African-American women (fi gure), 113
 

Guidelines for readers, 15
 

Guidry, L.
 

The Addiction and Trauma Recovery 


Integration Model, 171
 

Index 345
 
Gynecological issues 

overview, 7–8 

H 

HAART. See Highly active antiretroviral 


therapy
 

Haller, D.L.
 

pregnancy and co-occurring disorders, 


139
 

Harmon, L.W.
 

complexity of women’s work lives, 13
 

Hatmaker, C.M.
 

counselor gender impact on treatment 


retention, 142
 

HCV. See Hepatitis C virus
 

Health assessment and medical examination
 

importance of, 80–81
 

range of concerns, 286, 288–291
 

Women-Specific Health Assessment, 81
 

Health problems
 

issue overview, 7
 

Healthcare professionals
 

health assessment and medical 


examination, 80–81
 

impact of trauma and prenatal care, 102
 

referrals for further evaluation and 


treatment, 74
 

screening by, 73–74
 

substance abuse screening and, 61–62
 

Heffernan, K.
 

sexual orientation and substance use, 21
 

Helping Women Recover: A Program for 


Treating Addiction (Covington), 145, 171
 

Hepatitis. See also Hepatitis C virus
 

alcohol use and, 41
 

illicit drug use and, 52
 

prenatal cocaine exposure and, 50
 

risk factors, 20
 

Hepatitis C virus
 

addiction counselors’ contributions to 


treatment, 55
 

estimated number of people in the United 


States infected with, 53
 

HIV/AIDS and, 54
 

medical intervention, 54
 

prevention, 54
 

risk factors for contracting, 53–54
 

signs and symptoms, 53
 

treatment issues for women, 54–55
 

Herman, J.L.
 

Trauma and Recovery, 169
 

Heroin
 

African Americans and, 110
 

gender differences in metabolism and 


effects of, 47
 

homelessness and, 135
 

relapse rates, 98
 

Herzog, D.B.
 

eating disorders and substance use 


disorders, 175
 

HHANES. See Hispanic Health and Nutrition 


Examination Survey
 

Highly active antiretroviral therapy
 

HIV/AIDS treatment, 53
 

Hispanic Health and Nutrition Examination 


Survey
 

illicit drug use data, 105, 107
 

Hispanic/Latina population
 

acculturation and, 24, 26, 106, 107
 

alienation from cultural heritage and, 108
 

clinical treatment issues, 107–109
 

co-occurring mental disorders, 108
 

cultural sanctions against drinking by 


women, 105
 

defi nition, 16
 

demographics, 104
 

depression and, 21
 

familismo and, 107
 

gender socialization, 105–106
 

growth of, 104
 

hembrismo and, 108
 

HIV/AIDS and, 108
 

“La Casita” residential treatment 


program, 109
 

lesbian and bisexual women, 126
 

marianismo and, 108
 

misuse of OTC cough and cold medications 


and, 48
 

resiliency factors, 108–109
 

role of motherhood, 107
 

socioeconomic status of, 104, 105
 

substance use among, 104–105
 

women in the criminal justice system and, 


134
 

HIV/AIDS
 

African Americans and, 111
 

alcohol use and abuse and, 52–53
 

hepatitis C virus and, 54
 

Hispanic/Latina population and, 108
 

346 Index 
importance of testing for, 81
 

Native Americans and, 122
 

physiological effects of substance abuse 


and, 52–55
 

prenatal cocaine exposure and, 50
 

racial/ethnic factors, 39
 

risk factors, 20
 

socioeconomic status and, 39
 

substance use disorders and, 7
 

“Triangle of Risk” for, 122
 

Homelessness
 

factors contributing to, 135
 

interpersonal violence and, 70
 

percent of Americans experiencing, 135
 

physiological effects of substance abuse 


and, 39
 

sexual abuse and, 70
 

substance abuse among women who are 


homeless, 135
 

Homelessness Resource Center, 135
 

Hormone replacement therapy
 

alcohol use and abuse and, 42
 

Housing support services
 

description, 290, 291
 

Hughes, T.L.
 

CAGE sensitivity, 63
 

definitions of “lesbian,” “gay,” and 


“bisexual,” 124
 

sexual orientation and substance use, 21
 

Hurt, H.
 

prenatal cocaine exposure effects, 49–50
 

Hypertension
 

alcohol use and, 41
 

racial/ethnic factors, 39
 

I
 

IHS. See Indian Health Service 

Illicit drugs. See also specifi c drugs
 

African Americans and, 110
 

Asian/Pacific Americans and, 116–117
 

gender differences in metabolism and 


effects, 46–48
 

Hispanic/Latina population, 105
 

lesbian and bisexual women and, 124
 

Native Americans and, 119–120
 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug among women aged 18 or older by 


age group: 2003 (fi gure), 32
 

percentages of past-year abuse of or 

dependence on alcohol or any illicit 


drug by gender and age, 2006 (fi gure), 


31
 

pregnancy and, 28, 30
 

prevalence of use by women, 26
 

screening tools, 62–63
 

use of illicit drugs, alcohol, and tobacco 


by females aged 12 or older, past year 


and past month, numbers in thousands 


and percentages, 2006 (fi gure), 29
 

Immigrants. See also specific racial or ethnic 


groups
 

acculturation effect on substance use 


disorders, 24, 26
 

screening and assessment and, 58
 

Improving Cultural Competence in Substance 


Abuse Treatment, 32, 104
 

Incorporating Alcohol Pharmacotherapies Into 


Medical Practice (TIP 49), 78
 

Indian Health Service
 

focus groups for Native American women 


in treatment, 123
 

Individual therapy
 

eating disorders, 176
 

Infants. See Birth outcomes 

Infertility. See Reproductive issues 

Inhalants
 

Native Americans and, 120
 

Initiation of use
 

protective factors, 20, 21, 23
 

reasons for, 18
 

risk factors associated with, 18–26
 

Inpatient treatment. See Residential and 


inpatient treatment
 

Intake for Women and Children
 

description and uses, 78
 

Integration Self-Assessment for Providers
 

description, 164
 

Intensive outpatient treatment, ASAM Level 


II. See also Medically managed intensive 


inpatient treatment, ASAM Level IV; 


Outpatient treatment, ASAM Level I
 

description, 99
 

Interpersonal obstacles to treatment 

description, 84–85 

Interpersonal therapy
 

depression, 174
 

eating disorders, 176
 

Interpersonal violence. See also Trauma
 

African Americans and, 110
 

Index 347
 
estimate of the number of women who 


were physically assaulted, 155
 

percent of women with substance use 


disorders and a history of, 71
 

physical and sexual abuse by parents, 156
 

posttraumatic stress disorder and, 164
 

screening for, 71–72
 

sexuality and, 150
 

socioeconomic factors, 70
 

substance use disorders and, 23
 

violence and women (fi gure), 156
 

women as victims of intimate partner 


abuse, 155–156
 

Intrapersonal obstacles to treatment
 

description, 84
 

IOP. See Intensive outpatient treatment, ASAM 


Level II
 

IPT. See Interpersonal therapy
 

Iwo San Program
 

description, 112
 

J 

Jacobson, J.O.
 

women of color and treatment retention, 


138
 

JCAHO. See Joint Commission on Accreditation 


of Healthcare Organizations
 

Jennison, K.M.
 

risk for adult children of parents who 


abuse alcohol, 18–19
 

Jessup, M.
 

genetic risk factors, 19
 

Johnson, J.L.
 

genetic risk factors, 19
 

Johnson, K.A.
 

risk for adult children of parents who 


abuse alcohol, 18–19
 

Johnson, T.P.
 

CAGE sensitivity, 63
 

Joint Commission on Accreditation of 


Healthcare Organizations
 

psychosocial history guidelines, 77
 

Jumper Thurman, P.
 

Native Americans’ mistrust of treatment 


services, 86
 

K 

Kelly, P.J.
 

treatment retention factors, 142
 

Kelly, S.
 

cognitive-behavioral therapy for African-


American women, 113
 

Kendler, K.S.
 

genetic risk factors, 19
 

Kidney disease
 

heroin use and, 47
 

substance use disorders and, 7
 

Kilpatrick, D.G.
 

“vicious cycle” of substance abuse and 


violence, 23
 

L 

“La Casita” residential treatment program
 

description, 109
 

Language issues
 

available screening and assessment tools in 


multiple languages (fi gure), 80
 

language as a treatment obstacle, 86
 

screening and assessment, 59–60, 79
 

Laudet, A.
 

difficulty of involving male partners in 


women’s treatment, 20
 

Learning disabilities. See also Women with 


disabilities
 

screening and assessment and, 60
 

Leff, M.
 

genetic risk factors, 19
 

Legal issues
 

linking women with the legal system, 


289–290
 

as obstacles to treatment, 87, 110
 

Lesbian and bisexual women
 

clinical treatment issues, 124, 126
 

definitions of “lesbian,” “gay,” and 


“bisexual,” 124
 

demographics, 123–124
 

depression and, 21
 

partner substance abuse and, 20
 

physiological effects of substance abuse 


and, 39
 

prejudice and discrimination and, 126–
 

127
 

prescription drug abuse, 21
 

rate of substance use and dependence, 21
 

resiliency factors, 126–127
 

348 Index 
separate treatment groups for, 124
 

stability in relationships and, 126
 

substance use among, 124
 

violence and abuse and, 156
 

Lessons Learned: Residential Substance Abuse 

Treatment for Women and Their Children, 

108
 

Level of Care Utilization System for Psychiatric 


and Addiction Services
 

description and uses, 68, 298
 

Liebschutz, J.
 

questions to use in screening for 


interpersonal violence, 71
 

Life-course issues
 

caring for parents and partners, 14
 

educational, employment, and career, 13
 

elderly women, 14
 

identity and gender expectations, 13
 

longer life expectancy, 14
 

menopause, 13–14
 

pregnancy, parenting, and child care, 13
 

Life skills training
 

description, 289
 

Littlefi eld, M.B.
 

resiliency factors for African-American 


women, 113–114
 

Liver disease
 

alcohol use and, 41
 

hepatitis C virus and, 54
 

heroin use and, 47
 

substance use disorders and, 7
 

Lockwood, T.W.
 

spirituality of African Americans, 111
 

LOCUS. See Level of Care Utilization System 


for Psychiatric and Addiction Services
 

M 

Malnutrition
 

alcohol use and, 41
 

Managing Depressive Symptoms in Substance 


Abuse Clients During Early Recovery (TIP 


48), 67, 173
 

Marijuana
 

Asian/Pacific Americans and, 117
 

birth outcomes and, 51–52
 

gender differences in metabolism and 


effects of, 47
 

Hispanic/Latina population and, 105
 

misuse of OTC cough and cold medications 


and, 48
 

Native Americans and, 120 

Marital status. See also Partners 

risk factor for substance use disorders, 

xviii, 19–20 

Mason, E. 

treatment retention factors, 142
 

MAST. See Michigan Alcohol Screening Test
 

Medicaid
 

Early and Periodic Screening, Diagnostic, 


and Treatment, 294
 

treatment funding services, 294
 

Medically managed intensive inpatient 


treatment, ASAM Level IV. See also
 

Intensive outpatient treatment, ASAM Level 


II
 

description and uses, 102
 

Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs 

(TIP 43), 47, 51, 66, 78, 98
 

Melchior, L.A.
 

women’s response to outreach, 88
 

Men
 

Substance Abuse Treatment: 


Men’s Issues, 15
 

Menopausal hormone therapy
 

alcohol use and abuse and, 42
 

Menopause
 

issue overview, 13–14
 

Menstruation
 

alcohol use and, 41, 42
 

cocaine use and, 46
 

heroin effects on, 47
 

Mental Health Screening Form-III
 

description and uses, 67
 

Mental illness and disorders. See also Cooccurring disorders; specifi c disorders
 

adherence to treatment recommendations 


and, 40
 

co-occurring substance use and, 23–24
 

screening for, 66–70
 

service provision concerns, 286
 

services for children, 288, 290
 

Metabolic effects of alcohol, 40–41 

Methadone 

use in pregnancy, 51, 97–98 

Methamphetamine
 

Asian/Pacific Americans and, 116–117
 

birth outcomes and, 52
 

gender differences in metabolism and 


effects of, 46–47 

Index 349
 
Hispanic/Latina population and, 105
 

Native Americans and, 120
 

Methylenedioxy-methamphetamine
 

gender differences in metabolism and 


effects of, 46–47
 

Mexican Americans
 

acculturation effect on substance use 


disorders, 24
 

alcohol use by women, 105
 

MHSF-III. See Mental health Screening Form-


III
 

MI. See Motivational interviewing
 

Michigan Alcohol Screening Test
 

compared with T-ACE, 64
 

compared with TWEAK, 63
 

Miles, D.R.
 

pregnancy and co-occurring disorders, 


139
 

Miller, D.
 

The Addiction and Trauma Recovery 


Integration Model, 171
 

Trauma Reenactment Model, 171
 

Miller, Jean Baker
 

Toward a New Psychology of Women, 144
 

M.I.N.I. See Mini-International 


Neuropsychiatric Interview
 

Mini-International Neuropsychiatric Interview
 

description and uses, 67
 

Mood disorders. See also Depression; specifi c 

disorders 

postpartum depression and, 158
 

Moos, B.S.
 

benefits of Alcoholics Anonymous for 


women, 186
 

Moos, R.H.
 

benefits of Alcoholics Anonymous for 


women, 186
 

Mora, J.
 

alcohol use by Mexican American women, 


105
 

key questions for clinicians with Hispanic/
 

Latina clients, 107
 

Morgenstern, J.
 

case management study, 92
 

Motivational interviewing
 

pregnancy and, 96
 

Multidimensional Measure of Religiousness/
 

Spirituality
 

description and uses, 79–80
 

N 

Najavits, L.M. 

posttraumatic stress disorder in women 

with substance use disorders, 163–164
 

Seeking Safety, 145, 147, 164, 171–172
 

Woman’s Addiction Workbook, 145, 147
 

Nanehahal, K.
 

alcohol use and stroke, 41
 

Narcotics Anonymous
 

description, 291
 

NAS. See Neonatal abstinence syndrome
 

National Association for Children of Alcoholics
 

“Celebrating Families”TM, 153
 

National Center for Health Statistics, National 


Health Interview
 

tobacco use prevalence, 28
 

National Center on Addiction and Substance 


Abuse
 

initiation of substance use among women, 


27
 

National Comorbidity Study
 

co-occurring substance use and mental 


disorders, 23
 

National Epidemiologic Survey on Alcohol and 


Related Conditions
 

inverse relationship between rates of 


alcohol dependence and age, 127–128
 

National Institutes of Health
 

racial and ethnic disparities in health, 103
 

National Medical Expenditures Survey
 

prescription drug use among women, 26
 

National Survey on Drug Use and Health
 

cost of treatment, 11
 

description, 26
 

illicit drug use by women, 26
 

misuse of OTC cough and cold 


medications, 47–48
 

percent of females with substance 


dependence or abuse, 1
 

percentages of reasons for not receiving 


substance use treatment in the past 


year among women aged 18-49 who 


needed treatment and who perceived a 


need for it: 2004-2006 (fi gure), 85
 

substance abuse among Native Americans, 


119, 120
 

National Survey on Drug Use and Health 2003
 

age factors in substance use disorders, 30
 

prescription drug use among women, 26
 

350 Index 
National Survey on Drug Use and Health 2004
 

co-occurring disorders, 40
 

prescription drug use among women, 26
 

National Survey on Drug Use and Health 2005
 

percent of treatment programs providing 


special programs for women, 86
 

National Survey on Drug Use and Health 2006
 

rate of binge alcohol use among Asian/
 

Pacific Americans, 115
 

National Survey on Drug Use and Health 2006 


and 2007
 

illicit drug use during pregnancy, 28
 

past-month substance use, based on 


combined 2006 and 2007 data (fi gure), 


30
 

National Violence Against Women Survey
 

estimated number of women who were 


physically assaulted, 155
 

National Women’s Health Information Center
 

factors increasing a women’s chance of 


depression prior to deliver of a baby, 


158, 160
 

Native Americans. See also Alaska-Native 

population; American-Indian population
 

clinical treatment issues, 120
 

culturally congruent substance abuse 


services, 122–123
 

demographics, 119
 

family and community involvement, 123
 

federally-recognized Tribes, 119
 

fetal alcohol syndrome and, 122
 

forced acculturation and 


deculturalization, 120
 

historical trauma, 120
 

HIV/AIDS and, 122
 

lesbian and bisexual women, 126
 

mistrust of treatment services, 85–86
 

reservation-based treatment programs, 


120
 

resiliency factors, 123
 

substance use among, 119–120
 

trauma-informed services and, 120, 122
 

treatment barriers, 120
 

“two-spirit” persons, 126
 

Neonatal abstinence syndrome
 

opioid use and, 51
 

Nerve damage
 

substance use disorders and, 7
 

Neurological effects
 

alcohol-related neurodevelopmental 


disorder, 49
 

alcohol use and abuse, 45–46
 

Nguzo Saba: The Seven Principles
 

description, 112
 

Nicotine addiction. See Tobacco use
 

NIH. See National Institutes of Health
 

1996 National Household Survey on Drug 


Abuse
 

patterns of substance use in homosexual 


and heterosexual women, 39
 

Nishimoto, R.H.
 

treatment retention factors, 139
 

Note(s) to Clinicians or Administrators
 

clients with anxiety disorders, 161
 

clients with PTSD, 70
 

description, 15
 

factors increasing a women’s chance of 


depression prior to childbirth, 160
 

female-only therapy groups, 140
 

focus of clinical work on trauma, 171
 

HIV/AIDs evaluations for pregnant 


women, 51
 

key issues in trauma-related mental 


disorders, 172
 

methadone maintenance treatment and 


antidepressant treatment, 174
 

risk-taking behavior, 22
 

trauma-focused interventions, 166
 

women’s tendency to focus on problems 


or stressors other than their substance 


abuse, 34
 

Novelty-seeking behavior
 

risk factor for substance use disorders, 


20–21
 

NSDUH. See National Survey on Drug Use and 


Health
 

O 

OAS. See Office of Applied Studies 

Obesity
 

alcohol use and, 41
 

protective factor against developing 


substance use disorders, 24
 

Oetting and Beauvais Questionnaire
 

description, 59
 

Office of Applied Studies
 

case management access statistics, 92
 

Index 351
 
Office of the Surgeon General. See also Surgeon 


General
 

effect of mothers’ smoking cessation on 


their children, 28
 

Office on Women’s health
 

educational materials on eating disorders, 


177
 

Older women. See also Age factors; Elderly 


persons
 

clinical treatment issues, 130
 

demographics, 127
 

resiliency factors, 130
 

risk factors for alcohol dependence and 


prescription drug abuse, 127
 

in Rural America, 130
 

signs of alcohol-dependence and/or drug 


abuse, 128
 

substance use among, 127–128, 130
 

timing of onset of alcohol dependence, 127
 

Opioids
 

African Americans and, 110
 

Asian/Pacific Americans and, 117
 

birth outcomes and, 50–51
 

gender differences in metabolism and 


effects of, 47
 

withdrawal from, 66, 98
 

Opportunistic diseases
 

substance use disorders and, 7
 

Organization of the TIP, 15
 

Organizational change
 

administrative strategies for, 193–196 

Osteoporosis
 

alcohol use and, 42, 45
 

substance use disorders and, 7, 14
 

tobacco use and, 42, 45
 

OTC drugs. See Over-the-counter drugs 

Outpatient treatment, ASAM Level I. See also
 

Intensive outpatient treatment, ASAM Level 


II
 

appropriate use of, 98
 

child care and, 98
 

Outreach
 

effectiveness of, 88
 

major components, 88, 283
 

PROTOTYPES Outreach Program 


(fi gure), 91
 

trauma-informed treatment approach 


and, 166
 

Over-the-counter drugs
 

admission of women for treatment of 


abuse of, 32–33
 

gender differences in metabolism and 


effects of, 47–48
 

Overexercising
 

defi nition, 175
 

P 

Page, R.M.
 

negative self-image, 21
 

Panic disorders
 

co-occurring substance use, 23–24
 

Paranjape, A.
 

questions to use in screening for 


interpersonal violence, 71
 

Parenting
 

children who are not in a mother’s care, 


153–154
 

children with special needs, 154
 

desire of women to be caring and 


competent parents, 151
 

education in parenting and child 


development, 289
 

inadequate role models and, 151
 

issue overview, 10–11, 13
 

recovery and, 151–152
 

women with histories of trauma and, 153
 

Parenting programs
 

onsite child care and child specialists, 152
 

topics for parenting skills and relationship 


building, 152
 

women’s coping skills and, 152
 

Partial fetal alcohol syndrome
 

description, 49
 

Partners. See also Marital status
 

curricula for relationships in recovery, 


145–146
 

dynamic of one partner being the supplier 


and the other using the drug, 20, 27
 

effect of partner substance abuse, 20
 

ending significant relationships, 145
 

entering or staying in treatment and, 20
 

intimate partner violence screening tool 


(fi gure), 72
 

involving male partners in women’s 


treatment, 20, 145–147
 

safety issues for clients, 145
 

support from, 10, 21
 

352 Index 
tolerating or accepting a client’s 


relationships that the counselor fi nds 


objectionable, 145
 

women as caregivers for, 14
 

Patterns of use
 

executive summary, xviii–xix
 

initiation of use, 18
 

overview, 17–18
 

prevalence of substance use, 26–30
 

risk factors, xviii, 18–26
 

six patterns associated with women’s 


substance use, xix, 27
 

Peripheral neuropathy
 

substance use disorders and, 7
 

Personality disorders
 

eating disorders and, 176
 

postpartum depression and, 158
 

Personality types
 

characteristics of effective counselors, 


139, 140, 141–142
 

risk-seeking personality, 21
 

pFAS. See Partial fetal alcohol syndrome
 

Physical abuse. See also Trauma
 

history of as a risk factor for substance 

use disorders, 156–157
 

by parents, 156
 

risk to children of physical abuse from 


mothers who use substances, 152
 

survivor self-medication for depression or 


anxiety, 22
 

Physical responses to substances
 

issue overview, 7
 

telescoping effect, 7, 27, 40
 

Physiological effects and consequences of 

substance abuse
 

aging and, 39–40
 

alcohol, 40–46, 48–49, 52–55
 

co-occurring disorders and, 40
 

culture and, 38–39
 

developmental issues, 39–40
 

ethnicity and, 38–39
 

executive summary, xix–xx
 

factors infl uencing, 38–40
 

HIV/AIDS and, 52–55
 

homelessness and, 39
 

illicit drugs, 46–47, 49–55
 

over-the-counter medications, 47–48
 

overview, 37
 

prescription drugs, 47
 

research limitations, 38
 

sexual orientation and, 39
 

socioeconomic status and, 39
 

tobacco use, 48, 52
 

Plested, B.
 

Native Americans’ mistrust of treatment 


services, 86
 

Point-of-entry providers
 

goals and training guidelines for pointof-entry staff (non-substance-abuse 


treatment providers) (fi gure), 190
 

screening issues, 60, 73–74
 

training for, 189
 

Pooled or blended funding
 

defi nition, 293
 

Postpartum depression
 

as an under-diagnosed disorder, 159
 

anxiety and personality disorders and, 


158
 

Posttraumatic stress disorder
 

childhood sexual and physical abuse and, 


157
 

coping strategies, 163
 

Native Americans and, 122
 

prevalence among women, 160
 

PTSD Checklist, 70
 

rape and, 164
 

relapse and, 164
 

screening for, 68–70
 

self-harm and suicidal behavior and, 68
 

substance use disorders and, 22, 23–24, 


163–164
 

symptoms, 68–69, 161, 162
 

trauma-informed treatment approach, 


164–169
 

treatment of, 161, 163
 

Poundstone, K.E.
 

HIV/AIDS treatment and, 53
 

Practical Approaches in the Treatment of 


Women Who Abuse Alcohol and Other 


Drugs, 4, 273
 

Pregnancy. See also Birth outcomes; 

Reproductive issues
 

admission to treatment and, 33
 

alcohol use and abuse and, 28, 42, 48–49
 

childbirth education, 102
 

co-occurring disorders and, 139, 158, 160
 

Index 353
 
detoxification issues, 97–98, 151
 

early intervention during, 96
 

educational programs about the effects 


of alcohol, drug, and tobacco use, 

150–151
 

family planning education, 102
 

hepatitis C virus treatment and, 54
 

history of physical abuse and drug 


dependency, 23
 

HIV/AIDS and, 53
 

issue overview, 8, 10, 13
 

postpartum home visits, 102
 

postpartum relapse prevention, 184–186
 

prenatal care and, 28, 30
 

prevalence of substance use patterns, 27, 


28, 30
 

residential services for pregnant women, 


99, 101–102
 

Residential Women and Children/
 

Pregnant and Postpartum Women 


programs and, 100
 

screening instruments for pregnant 

women, 63–65
 

stress and, 150
 

treatment resources for pregnant women, 


86
 

treatment retention and, 139
 

withdrawal from opioids and, 66
 

Prescott, C.A.
 

genetic risk factors, 19
 

Prescott, L. 


benefits of consumer input, 187–188
 

Prescription drug use
 

admission of women for treatment, 32–33
 

older women and, 127, 128, 130
 

prevalence among women, 26
 

sexual orientation and, 21
 

Prescription drugs
 

gender differences in metabolism and 


effects of, 47
 

Pretreatment intervention groups
 

description, 91
 

Prevalence of substance use
 

across the life span, 30
 

alcohol, 26
 

among pregnant women, 28, 30
 

gender gap, 27, 30
 

illicit drugs, 26
 

prescription drugs, 26
 

tobacco, 26, 28
 

treatment admission characteristics, 31–33
 

use of illicit drugs, alcohol, and tobacco 


by females aged 12 or older, past year 


and past month, numbers in thousands 


and percentages, 2006 (fi gure), 29
 

Prevention services for children, 290
 

Price, A.
 

partner’s influence on a woman’s 


recovery, 145
 

Prochaska, J.J.
 

outcomes of smoking cessation programs 


in substance use disorder treatment, 


178
 

Project Return Foundation, Inc.
 

Mental Health Screening Form-III, 67
 

Protective factors
 

coping skills, 23
 

obesity, 24
 

parental warmth, 20
 

partner support, 21
 

religious and spiritual practices, 21
 

PROTOTYPES Outreach Program
 

description (fi gure), 91
 

A Provider’s Introduction to Substance Abuse 


Treatment for Lesbian, Gay, Bisexual, and 


Transgender Individuals, 22, 124, 147
 

PSH. See Psychosocial History assessment tool 

Psychological characteristics of women. See 

Biological and psychological characteristics 

of women 

The Psychological Maltreatment of Women 

Inventory
 

description and uses, 71
 

Psychosocial and cultural history
 

format for obtaining, 77
 

subheadings for, 77–78
 

Psychosocial History assessment tool
 

description and uses, 76
 

Psychosocial treatment of posttraumatic stress 


disorder: A practice-friendly review of 


outcome research, 163
 

PTSD. See Posttraumatic stress disorder
 

PTSD Checklist
 

description and uses, 70
 

354 Index 
R 

Racial/ethnic factors. See also Culture; 

Substance abuse among specifi c population 

groups and settings; specific races and 

ethnicity 

depression, 21, 173
 

health disparities, 103
 

misuse of OTC cough and cold 


medications, 48
 

percentage of admissions to substance 


abuse treatment programs by racial/
 

ethnic group in 2006 (fi gure), 33
 

physiological effects of substance abuse, 

38–39 

primary substance of abuse among women 


admitted for substance abuse treatment 


by racial/ethnic group by percentage 


(fi gure), 34
 

reluctance to seek treatment, 86
 

screening and assessment, 58–60
 

treatment admissions characteristics of 


racial/ethnic groups, 31–32, 33
 

Reader guidelines, 15
 

Recovery management
 

continuing care, 181–182
 

executive summary, xxii–xxiii
 

overview, 181
 

Recreational services for children, 290–291 

Refi nancing 

defi nition, 293–294 

Relapse 

client characteristics and, 183–184 

during the continuing care period, 181– 

182
 

heroin use and, 98
 

postpartum relapse prevention, 184–186
 

posttraumatic stress disorder and, 164
 

women-specific predictors of relapse and 


reactions to relapse (fi gure), 184
 

Relational Systems Change Model, 144, 194
 

Relationships. See also Partners; specifi c 


relationships 

curricula for relationships in recovery, 

145–146
 

disconnections, 143
 

exploring the history and infl uence of 


relationships: sociogram, 148–149
 

importance of in women’s lives, 138, 143
 

relational model approach to therapy, 


144, 194
 

skills related to improving the quality of, 

143–144 

Religious and spiritual practices. See also Faithbased initiatives
 

African Americans and, 111
 

assessment and, 79–80
 

Hispanic/Latina population and, 109
 

Multidimensional Measure of 


Religiousness/Spirituality, 79–80
 

as protective factors, 21
 

Religious Practice and Beliefs measurement, 79
 

Spiritual Well-Being Scale, 80
 

Religious Practice and Beliefs measurement
 

description and uses, 79
 

Reproductive issues. See also Pregnancy 

alcohol consumption, 40, 41–42 

substance use disorders, 7–8 

Research. See also specific studies and study 

authors 

benefits of consumer input, 187–188
 

issue overview, 2
 

Residential and inpatient treatment
 

appropriate uses for, 99
 

child care and, 86, 141, 287
 

children accompanying their mothers in, 


86, 100–101, 141
 

components, 99–100
 

creating a healing environment, 188
 

effectiveness of, 99
 

length of stay, 99, 100
 

settings for, 99
 

Residential Women and Children/Pregnant and 

Postpartum Women programs
 

funding for, 273
 

importance of, 281
 

outcomes, 100
 

Resource Panel members, 319–322
 

The Revised Conflict Tactics Scale
 

description and uses, 71
 

Risk factors
 

childhood sexual and physical abuse, 


156–157
 

co-occurring disorders, 23–24
 

continuing care period and, 182
 

discrimination, 24
 

familial substance abuse, 18–19
 

family of origin characteristics, xviii, 19
 

genetic, 19
 

hepatitis C virus, 53–54
 

marital status, 19–20
 

Index 355
 
personality measures, 20–21
 

sexual orientation, 21–22
 

socioeconomic status, 26
 

Risk-taking personality
 

risk factor for substance use disorders, 


20–21
 

Roberts, A.G.
 

treatment retention factors, 139
 

Robinson, P.L.
 

women of color and treatment retention, 


138
 

Romach, M.K.
 

hormonal changes and alcohol 


consumption, 42
 

Rural American women
 

clinical treatment issues, 131, 133
 

demographics, 130–131
 

resiliency factors, 133
 

risk factors for substance use, 131
 

substance use among, 131
 

RWC/PPW programs. See Residential Women 

and Children/Pregnant and Postpartum 

Women programs 

S 

Safety
 

assessing risk of harm to self or others, 68
 

partners and, 145
 

screening for acute safety risk related to 


serious intoxication or withdrawal, 

65–66 

trauma-informed treatment approach 

and, 167, 169–170 

SAMHSA. See Substance Abuse and Mental 

Health Services Administration 

SBIRT. See Screening, Brief Intervention, and 

Referral to Treatment Initiative 

SBORT. See Structured Behavioral Outpatient 

Rural Therapy
 

Scope of the TIP, 15
 

Screening. See also Assessment; specifi c 


screening instruments 

acculturation and language issues, 59–60 

acute safety risk related to serious 

intoxication or withdrawal, 65–66 

available screening and assessment tools in 

multiple languages (fi gure), 80
 

of children, 287
 

cognitive and learning disabilities and, 60
 

compared with assessment, 58
 

cutoff scores, 60–61
 

definition, xx, 58
 

domains to screen for, 61
 

eating disorders, 72–73
 

ethnicity and culture and, 58–60
 

executive summary, xx–xxi
 

factors of infl uence, 58–60
 

by healthcare providers in other settings, 


73–74
 

language issues, 59–60, 79
 

mental illness symptoms and mental 


disorders, 66–70
 

overview, 57–58, 283, 285
 

points of entry from other systems of care, 


60, 73–74
 

for pregnant women, 63–65
 

sexual orientation and, 60
 

socioeconomic status and, 60
 

substance abuse, 61–66
 

tobacco use, 63
 

Screening, Brief Intervention, and Referral to 


Treatment Initiative
 

description and uses, 74
 

Screening for acute safety risk related to serious 


intoxication or withdrawal
 

Clinical Institute Narcotic Assessment for 


Opioid Withdrawal, 65–66
 

Clinical Institute Withdrawal Assessment 


for Alcohol Withdrawal, 65
 

pregnant women and, 66
 

Screening for eating disorders
 

Eating Attitudes Test-26, 73
 

general and specific screening questions 


for persons with possible eating 


disorders (fi gure), 73
 

Screening for interpersonal violence
 

Abuse Assessment Screen, 71
 

Danger Assessment, 71
 

The Psychological Maltreatment of 


Women Inventory, 71
 

The Revised Conflict Tactics Scale, 71
 

StaT, 71
 

women with disabilities, 72
 

Screening for mental illness and disorders
 

anxiety disorders, 67–68
 

assessing risk of harm to self or others, 68
 

Beck Anxiety Inventory, 68
 

Beck Depression Inventory-II, 67
 

Brief Symptom Inventory, 67
 

Center for Epidemiologic Study 


Depression Scale, 67
 

356 Index 
depression, 67–68
 

General Health Questionnaire, 67
 

general screening instruments, 67
 

Level of Care Utilization System for 


Psychiatric and Addiction Services, 68
 

Mental Health Screening Form-III, 67
 

Mini-International Neuropsychiatric 


Interview, 67
 

posttraumatic stress disorder, 68–70
 

trauma, 68–70
 

Screening for substance abuse
 

AUDIT, 62
 

CAGE, 62–63, 74
 

CAGE-AID, 63
 

comfort level of the counselor or 


healthcare professional, 61–62
 

general alcohol and drug screening, 62–63
 

goal of, 61
 

instrument selection, 61
 

TCUDS II, 62
 

Screening instruments for pregnant women
 

5Ps, 65
 

T-ACE, 64–65
 

TWEAK, 63–64
 

Sedative-hypnotics
 

older women and, 128
 

withdrawal from, 66, 97, 98
 

Seeking Safety (Najavits), 145, 147, 164, 171–
 

172
 

Seizures
 

alcohol withdrawal and, 97
 

Selective serotonin reuptake inhibitors
 

depression treatment, 174
 

eating disorder treatment, 176
 

Self-harm
 

screening instruments, 68
 

Sellers, E.M.
 

hormonal changes and alcohol 


consumption, 42
 

Service delivery issues
 

treatment retention and, 141
 

Services for children of women in substance 


abuse treatment
 

clinical support services, 290–291
 

description, 279
 

whole-family perspective for, 281
 

Services Grant Program for Residential 

Treatment for Pregnant and Postpartum 

Women 

Lessons Learned: Residential Substance 


Abuse Treatment for Women and Their 


Children, 108
 

Sexual abuse. See also Trauma
 

African Americans and, 110
 

history of as a risk factor for substance 


use disorders, 156–157
 

impact of trauma and prenatal care, 102
 

lesbian and bisexual women and, 22, 156
 

Native Americans and, 120
 

by parents, 156
 

questions regarding (fi gure), 71
 

screening for, 70–71
 

sexuality and, 150
 

socioeconomic factors, 70
 

survivor self-medication for depression or 


anxiety, 22
 

Sexual dysfunction
 

substance abuse treatment and, 150
 

Sexual orientation. See also Lesbian and 


bisexual women 

demographics, 123–124 

physiological effects of substance abuse 

and, 39
 

risk factor for substance use disorders, 


20, 21–22
 

screening and assessment and, 60
 

substance abuse and healthy development 


of, 147
 

as a treatment obstacle, 86
 

Sexuality
 

fear of sex while abstinent, 147, 150
 

sexual and interpersonal violence, 150
 

sexual concerns during early recovery, 


147, 150
 

sexual dysfunction, 150
 

sexual identity, 147
 

sexually transmitted diseases, 150
 

treatment for substance abuse and 


changes in, 147
 

Sexually transmitted diseases. See also HIV/
 

AIDS; specifi c diseases
 

clinical issues, 150
 

increased risk for among women who 


abuse substances, 150
 

substance abuse and, 80–81
 

Short Acculturation Scale for Latinos
 

description, 59
 

Index 357
 
Simmel, C.
 

partner’s influence on a woman’s 


recovery, 145
 

Simoni, J.M.
 

“Triangle of Risk” for HIV/AIDS, 122
 

Singer, L.T.
 

prenatal cocaine exposure effects, 50
 

Smith, A.M.
 

birth outcomes and marijuana use, 52
 

Social characteristics of women
 

accessing treatment for substance abuse, 


12
 

caregiver role, 11
 

client-counselor expectations, 12
 

family/partner support, 10
 

help-seeking behavior, 11
 

interpersonal stressful life events and, 12
 

pregnancy, parenting, and child care, 


10–11
 

social relationships and family history, 


9–13
 

stigma as a barrier to treatment, 12–13, 85
 

Sociocultural context. See also Culture
 

Bronfenbrenner’s ecological model, 2–4
 

CSAT’s comprehensive model of care, 4
 

identity and gender expectations, 13
 

treatment obstacles, 85–86
 

a woman’s life in context (fi gure), 3
 

Socioeconomic status
 

African Americans, 109
 

Hispanic/Latina population, 104, 105
 

interpersonal violence and, 70
 

Native Americans, 119
 

physiological effects of substance abuse 


and, 39
 

risk factor for substance use disorders, 26
 

Rural American women, 130, 131
 

screening and assessment and, 60
 

sexual abuse and, 70
 

Spiritual practices. See Faith-based initiatives; 


Religious and spiritual practices
 

Spiritual Well-Being Scale
 

description and uses, 80, 301
 

SSRIs. See Selective serotonin reuptake 


inhibitors
 

Staffi ng issues 

clinical supervision, 190, 192–193 

male staff members, 188–189 

organizational change, 193–196 

training, 189–190
 

women-centered staff, 188
 

StaT
 

description and uses, 71
 

intimate partner violence screening tool 


(fi gure), 72
 

States
 

concentrations of Asian/Pacifi c 


Americans, 115
 

concentrations of Hispanic/Latina women, 


104
 

concentrations of Native Americans, 119
 

guidance to states: treatment standards 


for women with substance use 


disorders, 196
 

mandated reporting of child abuse or 


neglect, 88
 

Medicaid programs, 294
 

services needed in women’s substance 


abuse treatment (fi gure), 93–95 

state standard examples of gender-specifi c 

treatment (fi gure), 195–196 

STDs. See Sexually transmitted diseases 

Stevens, S.J. 

socioeconomic status of urban Native 


American women, 120
 

Stigma
 

as an obstacle to treatment, 12–13, 85
 

Strategies for treatment engagement 

case management, 91–92 

integration and centralization of services, 

87–88
 

outreach services, 88
 

pretreatment intervention groups, 91
 

Stroke
 

alcohol use and, 41
 

Structural obstacles to treatment
 

child care issues, 86
 

cultural competence of programs, 86
 

program structure, 87
 

transportation issues, 87
 

women with disabilities, 87
 

Structured Behavioral Outpatient Rural 


Therapy
 

description, 133
 

Substance abuse
 

defi nition, 16
 

Substance Abuse: Administrative Issues in 


Outpatient Treatment (TIP 46), 98
 

358 Index 
Substance Abuse: Clinical Issues in Intensive 


Outpatient Treatment (TIP 47), 143
 

Substance Abuse Among Older Adults (TIP 26), 


62, 127
 

Substance abuse among specifi c population 

groups and settings. See also Racial/ethnic 

factors 

African-American women, 109–115 

American-Indian and Alaska-Native 

women, 119–123 

Asian- and Pacifi c-American women, 

115–118
 

executive summary, xxi–xxii
 

Hispanic/Latina women, 104–109
 

older women, 127–130
 

overview, 103–104
 

sexual orientation, 123–127
 

women in Rural America, 130–133
 

women in the criminal justice system, 134
 

women who are homeless, 135
 

women with cognitive and physical 


disabilities, 133–134 

Substance Abuse and Mental Health Services 

Administration. See also National Survey on 

Drug Use and Health; Treatment Episode 

Data Set; specifi c publications 

Homelessness Resource Center, 135
 

1996 National Household Survey on Drug 


Abuse, 39
 

Screening, Brief Intervention, and 


Referral to Treatment Initiative, 74
 

Women, Co-Occurring Disorders and 


Violence Study, 71, 170
 

Women Embracing Life and Living 


(WELL) Project, 165
 

Substance Abuse and Trauma, 9, 24, 70, 155, 


160
 

Substance Abuse Prevention and Treatment 


Block Grant
 

description, 294
 

Substance Abuse Treatment: Group Therapy, 

141
 

Substance Abuse Treatment and Domestic 


Violence (TIP 25), 9, 23, 71, 78, 145
 

Substance Abuse Treatment and Men’s Issues,
 

Substance Abuse Treatment for Adults in the 


Criminal Justice System (TIP 44), 78, 134
 

Substance Abuse Treatment for People Who Are 


Homeless, 135
 

Substance Abuse Treatment for Persons with 


Child Abuse and Neglect Issues (TIP 36), 9, 


71, 78, 108, 157
 

Substance Abuse Treatment for Persons with 


Co-Occurring Disorders (TIP 42), 66, 67, 


73, 78, 155, 157, 160
 

Substance Abuse Treatment for Persons with 


HIV/AIDS (TIP 37), 53
 

Substance abuse treatment for women. See also 

Comprehensive Substance Abuse Treatment 

Model for Women and Their Children 

executive summary, xxii
 

overview, 137
 

treatment issues and needs, 143–177
 

treatment retention, 137–143
 

Substance Abuse Treatment with American 


Indians and Alaska Natives, 119
 

Substance Dependent PTSD Therapy (SDPT),
 

172–173
 

Suicide attempts and parasuicidal behavior
 

screening instruments, 68
 

Support systems for women
 

12-Step programs, 186
 

Women for Sobriety, 186
 

Supportive therapy 

treatment retention and, 139–140 

Surgeon General. See also Office of the Surgeon 

General 

Report on Women and Smoking, 63
 

SWBS. See Spiritual Well-Being Scale
 

Systems model
 

description, 2–4
 

a woman’s life in context (fi gure), 3
 

Systems obstacles to treatment
 

child welfare system, 87
 

legal issues, 87
 

T 

T-ACE
 

compared with Alcohol Use Disorder 


Identification Test, 64
 

compared with Michigan Alcohol 


Screening Test, 64
 

compared with the TWEAK, 63–64
 

description and uses, 64–65
 

T-ACE Questionnaire (fi gure), 64
 

TANF. See Temporary Assistance to Needy 


Families
 

TCUDS II. See Texas Christian University Drug 


Screen II
 

Index 359
 

15 
TEDS. See Treatment Episode Data Set
 

Telescoping effect, xix, 7, 27, 40
 

Temporary Assistance to Needy Families
 

case management study, 92
 

description, 292, 294
 

women as recipients, 13
 

Terminology, 16
 

Texas Christian University Brief Intake
 

description and uses, 78–79
 

Texas Christian University Drug Screen II
 

description and uses, 62
 

Theidon, K.S.
 

function of case management, 91–92
 

Therapeutic alliance
 

assessment interviews and, 75
 

challenges in maintaining a therapeutic 


alliance: child welfare and issues of 


confi dentiality, 88
 

treatment retention and, 141–143
 

Timko, C.
 

benefits of Alcoholics Anonymous for 


women, 186
 

Tobacco use
 

birth outcomes and, 52
 

“gateway” concept, 28
 

osteoporosis and, 42, 45
 

physiological effects, 48, 52
 

postpartum relapse and, 185–186
 

pregnancy and, 28
 

prevalence among women, 26, 27, 28
 

referrals of women for smoking cessation, 


63
 

screening for, 63
 

smoking cessation programs, 178–179
 

substance use disorder treatment and, 


177–179 

use of illicit drugs, alcohol, and tobacco 


by females aged 12 or older, past year 


and past month, numbers in thousands 


and percentages, 2006 (fi gure), 29
 

Toward a New Psychology of Women (Miller), 


144
 

Training
 

counselors, 189–190, 193
 

life skills, 289
 

point-of-entry providers, 189
 

Transportation
 

services for women, 291
 

Trauma. See also specific types of trauma
 

African Americans and, 110
 

clinical supervision issues, 192–193
 

detoxification and, 97
 

history of traumatic events association 


with substance use disorders, 22–23
 

issue overview, 2, 8–9
 

models of recovery, 169–171
 

Native Americans and, 120, 122
 

parenting issues for women with trauma 


histories, 153
 

questions to screen for trauma history 


(fi gure), 69
 

reconnection stage, 170–171
 

relationship between trauma and 


substance abuse, 155
 

remembrance and mourning stage, 170
 

residential treatment settings and, 100
 

risk factor for substance use disorders, 


22–23
 

Rural American women and, 131
 

safety stage, 169–170
 

screening for, 68–70
 

sexuality and, 150
 

treatment programs and curricula, 171–
 

173
 

vicarious traumatization of counselors, 


192–193
 

vulnerability to additional trauma, 22–23
 

women’s responses to, 154
 

Trauma Adaptive Recovery Group Education 

and Therapy (TARGET), 172
 

Trauma and Recovery (Herman), 169
 

Trauma-informed treatment approach
 

affect regulation and, 168
 

boundaries between counselors and clients 


and, 168
 

clinical considerations, 165–169, 286
 

creating a healing environment, 188
 

goal of, 167
 

level of distress tracking, 168
 

listening skills of counselors and, 168
 

Native Americans and, 120, 122
 

normalizing the symptoms, 166–167
 

posttraumatic stress disorder and, 164–
 

169
 

timing and pacing and, 168
 

triggering and retraumatization and, 169
 

Women Embracing Life and Living 


(WELL) Project, 165
 

for women with trauma histories, 153, 


164–165
 

360 Index 
Trauma Recovery and Empowerment Model 

(TREM), 172
 

Treating Addicted Survivors of Trauma, 172
 

Treatment admissions characteristics
 

patterns of substance use, 31–33 

percentages of past-year abuse of or 


dependence on alcohol or any illicit 


drug among women aged 18 or older by 


age group: 2003 (fi gure), 32
 

primary substance of abuse among women 


admitted for substance abuse treatment 


by racial/ethnic group by percentage 


(fi gure), 34
 

racial/ethnic groups, 31–32, 33
 

referral routes, 31
 

self-referral, 31
 

Treatment engagement 

barriers to, xxi, 83–87 

case management, 91–92 

challenges in maintaining a therapeutic 

alliance: child welfare and issues of 

confi dentiality, 88
 

confidentiality issues, 87, 88
 

outreach services, 88
 

overview, 83
 

pretreatment intervention groups, 91
 

strategies for, 87–92
 

Treatment environment
 

creating a healing environment, 188
 

treatment retention and, 139–140
 

Treatment Episode Data Set
 

age of initiation of use, 18
 

alcohol as the primary substance of abuse 


among women, 31
 

alcohol use among African Americans, 


109–110
 

Hispanic/Latina illicit drug use data, 105
 

percent of Asian/Pacifi c Americans 


identifying alcohol as their primary 


drug of choice, 116
 

percent of pregnant women admitted to 


treatment, 33
 

substance preferences for racial/ethnic 


groups, 32
 

Treatment of Adolescents with Substance Use 


Disorders (TIP 32), 15
 

Treatment outcomes
 

couples therapy and, 138
 

factors infl uencing, 182–186
 

family therapy and, 138
 

gender as a predictor of success, 182
 

integrated trauma treatment and, 182
 

length of stay as a predictor of, 137
 

outcomes of smoking cessation programs 


in substance use disorder treatment, 


178
 

relapse variables, 183–186
 

Treatment placement and planning
 

ASAM’s Patient Placement Criteria, 92, 


95–102
 

care planning for children, 287
 

client involvement in, 92
 

considerations, 92, 285
 

detoxifi cation, 96–98
 

early intervention, 95–96
 

executive summary, xx–xxi
 

intensive outpatient treatment, 99
 

levels of care, 92, 95–102
 

medically managed intensive inpatient 


treatment, 102
 

outpatient treatment, 98–99
 

overview, 83, 92
 

residential and inpatient treatment, 86, 


99–102 

services needed in women’s substance 

abuse treatment (fi gure), 93–95 

Treatment retention
 

client’s confidence in the process, 142
 

criminal justice and child protective 


services referral and involvement and, 

139
 

defi nition, 137
 

effective therapeutic styles and, 140
 

factors infl uencing, 138–142
 

improving transitions and retention rates, 


142
 

length of stay as a predictor of 


posttreatment outcome, 137
 

pregnancy and, 139
 

relationships and, 138
 

same-sex versus mixed-gender groups, 


140–141
 

service delivery issues, 141
 

sociodemographics, 138
 

theoretical approaches to treatment and, 


139–140, 142–143 

therapeutic alliance and counselor 

characteristics, 141–142 

Index 361
 
therapist characteristics and, 139, 140, 


141–142 

treatment environment and, 139–140 

type of treatment services and, 140–141 

Treloar, C.
 

partner relationship effect on substance 


use, 27
 

Tuberculosis
 

illicit drug use and, 52
 

TWEAK
 

compared with CAGE, 63
 

compared with Michigan Alcohol 


Screening Test, 63
 

compared with the T-ACE, 63–64
 

description and uses, 63
 

TWEAK Questionnaire: Women (fi gure), 


64
 

12-Step programs
 

effectiveness of, 186
 

relapse prevention and, 186
 

treatment outcomes, 182
 

U 

Ulcers
 

alcohol use and, 41
 

Underhill, B.
 

sexual orientation and substance use, 21
 

Unemployment. See also Employment
 

Native Americans and, 119
 

risk factor for substance use disorders, 26
 

Unifi ed fi scal planning 

description, 293–294 

U.S. Department of Agriculture 

light, moderate, and heavy drinking 


defi nitions, 41
 

U.S. Department of Health and Human Services 

light, moderate, and heavy drinking 

defi nitions, 41
 

Office on Women’s health, 177
 

U.S. Department of Justice 

estimate of the percent of females in 


the criminal justice system who are 


dependent on or abusing drugs, 134
 

U.S. Preventive Services Task Force 

questions to use in screening for 


depression, 67
 

362 

V 

Vannicelli, M.
 

cultural competence of treatment 


programs, 86
 

Violence. See Domestic violence; Interpersonal 


violence
 

Viral Hepatitis and Substance Use Disorders, 55
 

Volk, R.J.
 

screening by healthcare providers, 74
 

W 

WCDVS. See Women, Co-Occurring Disorders 


and Violence Study
 

Web sites
 

Level of Care Utilization System for 


Psychiatric and Addiction Services, 68
 

Mini-International Neuropsychiatric 


Interview, 67
 

National Center for PTSD, 70
 

Office on Women’s health, 177
 

SAMHSA’s Women, Co-Occurring 


Disorders and Violence Study, 170
 

Texas Christian University Drug Screen 


II, 62
 

Weiderpass, E.
 

cancer and alcohol use, 42
 

Weir, B.W.
 

socioeconomic status effect on screening, 


60
 

Widowed women
 

alcohol use and, 128
 

physical and mental health issues, 14
 

Williams Lake Band, Canada
 

alcohol- and drug-free community 


example, 123
 

Wilsnack, S.C.
 

sexual orientation and substance use, 21
 

Withdrawal. See Screening for acute safety risk 


related to serious intoxication or withdrawal; 


specifi c drugs
 

Woman’s Addiction Workbook (Najavits), 145, 


147
 

Women, Co-Occurring Disorders and Violence 


Study
 

description, 71, 152, 170
 

including consumers in all aspects of the 


study design, 187
 

Index 
Women Embracing Life and Living (WELL) 

Project
 

description, 165
 

Self-Assessment for Providers, 313–317
 

Toolkit, 313
 

Women for Sobriety
 

description, 186
 

Women of color
 

defi nition, 16
 

sexual orientation and, 126
 

treatment retention and, 138
 

Women-Specific Health Assessment
 

description and uses, 81
 

Women with disabilities. See also Cognitive 


impairment; Learning Disabilities
 

co-occurring mental disorders and, 134
 

factors increasing the likelihood of 


substance abuse and dependence, 134
 

interpersonal violence screening and, 72
 

obstacles to treatment, 87
 

substance use among, 133–134
 

trauma history and, 134
 

Women’s Addiction Workbook, 79
 

Women’s Recovery Group
 

manual-based relapse prevention (fi gure), 


185
 

relapse prevention and, 183–184, 185
 

Women’s treatment issues and needs. See also 

Pregnancy
 

co-occurring disorders, 157–177
 

influence of family, 143–145
 

parenting, 151–154
 

partner relationships, 145–147
 

relational model approach, 144
 

relationships and the need for connection, 


143
 

sexuality, 147, 150
 

tobacco use, 177–179
 

trauma history, 154–157
 

World Health Organization
 

alcohol as a risk factor of diseases, 40
 

Wraparound services
 

defi nition, 293
 

WRG. See Women’s Recovery Group
 

Y 

Young, N.K. 

co-occurrence of a substance use disorder 


and involvement in the child welfare 


system, 87
 

Youth Risk Behavior Survey 2007
 

prevalence of alcohol and other drug use 


among adolescent Hispanic/Latina 


females, 105
 

Z 

Zlotnick, C.
 

family therapy and treatment outcomes, 


138
 

Index 363
 
 

CSAT TIPs and Publications Based on TIPs 

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of the Nation’s alcohol and drug 

abuse treatment service system. 

What Is a Quick Guide? 

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is divided 

into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page numbers from the 

original TIP are referenced so providers can refer back to the source document for more information. 

What Are KAP Keys? 

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and summaries 

of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept within a treatment 

provider’s reach and consulted frequently. The Keys allow you—the busy clinician or program administrator—to locate information easily 

and to use this information to enhance treatment services. 

TIP 1 	 State Methadone Treatment Guidelines—Replaced by 

TIP 43 

TIP 2* Pregnant, Substance-Using Women— BKD107 

Quick Guide for Clinicians QGCT02 

KAP Keys for Clinicians KAPT02 

TIP 3 	 Screening and Assessment of Alcohol- and Other DrugAbusing Adolescents—Replaced by TIP 31 

TIP 4 	 Guidelines for the Treatment of Alcohol- and Other 

Drug-Abusing Adolescents—Replaced by TIP 32 

TIP 5 	 Improving Treatment for Drug-Exposed Infants— 

BKD110 

TIP 6* Screening for Infectious Diseases Among Substance 

Abusers—BKD131 

Quick Guide for Clinicians QGCT06 

 KAP Keys for Clinicians KAPT06 

TIP 7 	 Screening and Assessment for Alcohol and Other Drug 

Abuse Among Adults in the Criminal Justice System— 

Replaced by TIP 44 

TIP 8 	 Intensive Outpatient Treatment for Alcohol and Other 

Drug Abuse—Replaced by TIPs 46 and 47 

TIP 9 	 Assessment and Treatment of Patients With Coexisting 

Mental Illness and Alcohol and Other Drug Abuse— 

Replaced by TIP 42 

TIP 10 Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients—Replaced by TIP 43 

TIP 11* Simple Screening Instruments for Outreach for 

Alcohol and Other Drug Abuse and Infectious 

Diseases— BKD143 

Quick Guide for Clinicians QGCT11
 

KAP Keys for Clinicians KAPT11
 

TIP 12 Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice 

System—Replaced by TIP 44 

TIP 13 Role and Current Status of Patient Placement Criteria 

in the Treatment of Substance Use Disorders—BKD161 

Quick Guide for Clinicians QGCT13 

Quick Guide for Administrators QGAT13 

KAP Keys for Clinicians KAPT13 

TIP 14 Developing State Outcomes Monitoring Systems for 

Alcohol and Other Drug Abuse Treatment—BKD162 

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug 

Abusers—Replaced by TIP 37 

TIP 16 Alcohol and Other Drug Screening of Hospitalized 

Trauma Patients—BKD164 

Quick Guide for Clinicians QGCT16 

KAP Keys for Clinicians KAPT16 

TIP 17 Planning for Alcohol and Other Drug Abuse Treatment 

for Adults in the Criminal Justice System—Replaced by 

TIP 44 

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues for 

Alcohol and Other Drug Abuse Treatment Providers— 

BKD173
 

Quick Guide for Clinicians QGCT18
 

KAP Keys for Clinicians KAPT18
 

TIP 19 Detoxification From Alcohol and Other Drugs—Replaced by TIP 45 

TIP 20 Matching Treatment to Patient Needs in Opioid Substitution Therapy—Replaced by TIP 43 

*Under revision 

365 
TIP 21 	Combining Alcohol and Other Drug Abuse Treatment 

With Diversion for Juveniles in the Justice System— 

(SMA) 08-4073 

Quick Guide for Clinicians and Administrators 

QGCA21 

TIP 22 LAAM in the Treatment of Opiate Addiction—Replaced 

by TIP 43 

TIP 23 Treatment Drug Courts: Integrating Substance Abuse 

Treatment With Legal Case Processing— 

(SMA) 08-3917 

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for Primary Care 

Clinicians—(SMA) 08-4075 

Concise Desk Reference Guide BKD123 

Quick Guide for Clinicians QGCT24 

KAP Keys for Clinicians KAPT24 

TIP 25 Substance Abuse Treatment and Domestic Violence— 

(SMA) 08-4076 

Linking Substance Abuse Treatment and Domestic Violence Services: A Guide for Treatment Providers MS668 

Linking Substance Abuse Treatment and Domestic Violence Services: A Guide for Administrators MS667 

Quick Guide for Clinicians QGCT25
 

KAP Keys for Clinicians KAPT25
 

TIP 26 Substance Abuse Among Older Adults—(SMA) 08-3918 

Substance Abuse Among Older Adults: A Guide for 

Treatment Providers MS669 

Substance Abuse Among Older Adults: A Guide for 

Social Service Providers MS670 

Substance Abuse Among Older Adults: Physician’s Guide 

MS671
 

Quick Guide for Clinicians QGCT26
 

KAP Keys for Clinicians KAPT26
 

TIP 27 Comprehensive Case Management for Substance Abuse 

Treatment—(SMA) 08-4215 

Case Management for Substance Abuse Treatment: A 

Guide for Treatment Providers MS673 

Case Management for Substance Abuse Treatment: A 

Guide for Administrators MS672 

Quick Guide for Clinicians QGCT27 

Quick Guide for Administrators QGAT27 

TIP 28* Naltrexone and Alcoholism Treatment—(SMA) 05-4077 

Naltrexone and Alcoholism Treatment: Physician’s 

Guide MS674 

Quick Guide for Clinicians QGCT28 

KAP Keys for Clinicians KAPT28 

TIP 29 Substance Use Disorder Treatment for People With 

Physical and Cognitive Disabilities—(SMA) 08-4078 

Quick Guide for Clinicians QGCT29 

Quick Guide for Administrators (SMA) 08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30 Continuity of Offender Treatment for Substance Use 

Disorders From Institution to Community— 

(SMA) 08-3920 

Quick Guide for Clinicians QGCT30
 

KAP Keys for Clinicians KAPT30
 

TIP 31 Screening and Assessing Adolescents for Substance Use 

Disorders—(SMA) 08-4079 

See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance Use Disorders—(SMA) 08-4080 

Quick Guide for Clinicians QGC312 

KAP Keys for Clinicians KAP312 

TIP 33 Treatment for Stimulant Use Disorders—(SMA) 06-4209 

Quick Guide for Clinicians QGCT33 

KAP Keys for Clinicians KAPT33 

TIP 34 Brief Interventions and Brief Therapies for Substance 

Abuse—(SMA) 07-3952 

Quick Guide for Clinicians QGCT34 

KAP Keys for Clinicians KAPT34 

TIP 35 Enhancing Motivation for Change in Substance Abuse 

Treatment—(SMA) 08-4212 

Quick Guide for Clinicians QGCT35 

KAP Keys for Clinicians KAPT35 

TIP 36 Substance Abuse Treatment for Persons With Child 

Abuse and Neglect Issues—(SMA) 08-3923 

Quick Guide for Clinicians QGCT36 

KAP Keys for Clinicians KAPT36 

Helping Yourself Heal: A Recovering Woman’s Guide to 

Coping With Childhood Abuse Issues—(SMA) 08-4132 

Available in Spanish: PHD981S 

Helping Yourself Heal: A Recovering Man’s Guide to 

Coping With the Effects of Childhood Abuse— 

(SMA) 08-4134 

Available in Spanish: PHD1059S 

TIP 37 Substance Abuse Treatment for Persons With HIV/ 

AIDS—(SMA) 08-4137 

Quick Guide for Clinicians MS678 

KAP Keys for Clinicians KAPT37 

Drugs, Alcohol, and HIV/AIDS: A Consumer Guide— 

(SMA) 08-4127 

Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for 

African Americans—(SMA) 07-4248 

366 
 

 

 

 

TIP 38 Integrating Substance Abuse Treatment and Vocational 


Services—(SMA) 06-4216
 

Quick Guide for Clinicians QGCT38
 

Quick Guide for Administrators QGAT38
 

KAP Keys for Clinicians KAPT38
 

TIP 39 Substance Abuse Treatment and Family Therapy— 

(SMA) 08-4219
 

Quick Guide for Clinicians QGCT39
 

Quick Guide for Administrators QGAT39
 

TIP 40 Clinical Guidelines for the Use of Buprenorphine in the 


Treatment of Opioid Addiction—(SMA) 07-3939
 

Quick Guide for Physicians QGPT40
 

KAP Keys for Physicians KAPT40
 

TIP 41 Substance Abuse Treatment: Group Therapy—(SMA) 


05-3991
 

Quick Guide for Clinicians QGCT41
 

TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders—(SMA) 08-3992
 

Quick Guide for Clinicians (SMA) 07-4034
 

Quick Guide for Administrators QGAT42
 

KAP Keys for Clinicians (SMA) 08-4036
 

TIP 43 Medication-Assisted Treatment for Opioid Addiction in 


Opioid Treatment Programs—(SMA) 08-4214
 

Quick Guide for Clinicians QGCT43
 

KAP Keys for Clinicians (SMA) 07-4108
 

TIP 44 Substance Abuse Treatment for Adults in the Criminal 


Justice System—(SMA) 05-4056
 

Quick Guide for Clinicians QGCT44
 

KAP Keys for Clinicians (SMA) 07-4150
 

TIP 45 Detoxification and Substance Abuse Treatment—(SMA) 


08-4131
 

Quick Guide for Clinicians (SMA) 06-4225
 

KAP Keys for Clinicians (SMA) 06-4224
 

Quick Guide for Administrators (SMA) 06-4226
 

TIP 46 Substance Abuse: Administrative Issues in Outpatient 


Treatment—(SMA) 06-4157
 

Quick Guide for Administrators—(SMA) 07-4232
 

TIP 47 Substance Abuse: Clinical Issues in Outpatient Treatment—(SMA) 06-4182
 

Quick Guide for Clinicians—(SMA) 07-4233
 

KAP Keys for Clinicians—(SMA) 07-4251
 

TIP 48 Managing Depressive Symptoms in Substance Abuse 


Clients During Early Recovery—(SMA) 08-4353
 

TIP 49 Incorporating Alcohol Pharmacotherapies Into Medical 


Practice—(SMA) 09-4380


 TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment—(SMA) 09-4381
 

TIP 51 Substance Abuse Treatment: Addressing the Specifi c 


Needs of Women—(SMA) 09-4426
 

TIP 52 Clinical Supervision and Professional Development of 


the Substance Abuse Counselor—(SMA) 09-4435
 

367 
368 

 

Treatment Improvement Protocols (TIPs) from the Substance Abuse and Mental Health Services 

Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT) 

Place the quantity (up to 5) next to the publications you would like to receive and print your mailing address below. 

___TIP 2* BKD107 

___QG+ for Clinicians QGCT02 

___KK+ for Clinicians KAPT02 

___TIP 5 BKD110 

___TIP 6* BKD131 

___QG for Clinicians QGCT06 

___KK for Clinicians KAPT06 

___TIP 11* BKD143 

___QG for Clinicians QGCT11 

___KK for Clinicians KAPT11 

___TIP 13 BKD161 

___QG for Clinicians QGCT13 

___QG for Administrators QGAT13 

___KK for Clinicians KAPT13 

___TIP 14 BKD162 

___TIP 16 BKD164 

___QG for Clinicians QGCT16 

___KK for Clinicians KAPT16 

___TIP 18 BKD173 

___QG for Clinicians QGCT18 

___KK for Clinicians KAPT18 

___TIP 21 (SMA) 08-4076
 

___QG for Clinicians & Administrators

 QGCA21 

___TIP 23 (SMA) 08-3917
 

___QG for Administrators QGAT23 

___TIP 24 (SMA) 08-4075
 

___Desk Reference BKD123
 

___QG for Clinicians QGCT24
 

___KK for Clinicians KAPT24 

___TIP 25 (SMA) 08-4076
 

___Guide for Treatment Providers MS668 

___Guide for Administrators MS667
 

___QG for Clinicians QGCT25 

___KK for Clinicians KAPT25 

___TIP 26 (SMA) 08-3918
 

___Guide for Treatment Providers MS669
 

___Guide for Social Service Providers

 MS670 

___Physician’s Guide MS671
 

___QG for Clinicians QGCT26 

___KK for Clinicians KAPT26 

___TIP 27 (SMA) 08-4215
 

___Guide for Treatment Providers MS673 

___Guide for Administrators MS672
 

___QG for Clinicians QGCT27 

___QG for Administrators QGAT27 

___TIP 29 (SMA) 08-4078
 

___QG for Clinicians QGCT29 

___QG for Administrators (SMA) 08-3592
 

___KK for Clinicians KAPT29 

___TIP 30 (SMA) 08-3920 

___QG for Clinicians QGCT30 

___KK for Clinicians KAPT30 

___TIP 31 (SMA) 08-4079 

 (see products under TIP 32)
 

___TIP 32 (SMA) 08-4080
 

___QG for Clinicians QGC312 

___KK for Clinicians KAP312 

___TIP 33 (SMA) 06-4209 

___QG for Clinicians QGCT33
 

___KK for Clinicians KAPT33 

___TIP 34 (SMA) 07-3952
 

___QG for Clinicians QGCT34
 

___KK for Clinicians KAPT34 

___TIP 35 (SMA) 08-4212
 

___QG for Clinicians QGCT35 

___KK for Clinicians KAPT35 

___TIP 36 (SMA) 08-3923
 

___QG for Clinicians QGCT36
 

___KK for Clinicians KAPT36
 

___Brochure for Women (English) 

(SMA) 08-4132
 

___Brochure for Women (Spanish)

 PHD981S
 

___Brochure for Men (English) 

(SMA) 08-4134 

___Brochure for Men (Spanish)

 PHD1059S 

___TIP 37 (SMA) 08-4137 

___QG for Clinicians MS678
 

___KK for Clinicians KAPT37
 

___Consumer Guide (SMA) 08-4127
 

___Consumer Guide for African
 

Americans (SMA) 07-4248 

___TIP 38 (SMA) 06-4216
 

___QG for Clinicians QGCT38|
 

___QG for Administrators QGAT38 

___KK for Clinicians KAPT38 

___TIP 39 (SMA) 08-4219
 

___QG for Clinicians QGCT39
 

___QG for Administrators QGAT39 

___TIP 40 (SMA) 07-3939
 

___QG for Physicians QGPT40 

___KK for Physicians KAPT40 

___TIP 41 (SMA) 05-3991
 

___QG for Clinicians QGCT41 

___TIP 42 (SMA) 08-3992
 

___QG for Clinicians (SMA) 07-4034
 

___QG for Administrators QGAT42

 ___KK for Clinicians (SMA) 08-4036 

___TIP 43 (SMA) 08-4214
 

___QG for Clinicians QGCT43 

___KK for Physicians (SMA) 07-4108 

___TIP 44 (SMA) 05-4056
 

___QG for Clinicians QGCT44

 ___KK for Clinicians (SMA) 07-4150 

___TIP 45 (SMA) 08-4131
 

___QG for Clinicians (SMA) 06-4225
 

___QG for Administrators (SMA) 06-4226
 

___KK for Clinicians (SMA) 06-4224 

___TIP 46 (SMA) 06-4151
 

___QG for Administrators (SMA) 07-4232 

___TIP 47 (SMA) 06-4182
 

___QG for Clinicians (SMA) 07-4233

 ___KK for Clinicians (SMA) 07-4251 

___TIP 48 (SMA) 08-4353 

___TIP 49 (SMA) 09-4380 

___TIP 50 (SMA) 09-4381 

___TIP 51 (SMA) 09-4426
 

___TIP 52 (SMA) 09-4435 

*Under revision 

+QG = Quick Guide; KK = KAP Keys 

Name:___________________________________________________________________________________________________________________ 

Address:________________________________________________________________________________________________________________ 

City, State, Zip:__________________________________________________________________________________________________________ 

Phone and e-mail:________________________________________________________________________________________________________ 

You can either mail this form or fax it to (240) 221-4292. Publications also can be ordered by calling SAMHSA’s NCADI at 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

TIPs can also be accessed online at http://www.kap.samhsa.gov. 
 369

.........

STAMP

SAMHSA’s National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, MD 20847-2345

.................................................................... ..................................................................... FOLD

..................................................................... ..................................................................... FOLD ........
Substance Abuse Treatment:
 

Addressing the Specifi c
 

Needs of Women
 

The primary goal of this TIP, Substance Abuse Treatment: Addressing the Specific Needs of Women, 

is to assist substance abuse treatment providers in offering effective, up-to-date treatment to adult 

women with substance use disorders. This TIP reviews gender-specific research and best practices 

beginning with the common patterns of initiation of substance use among women and extending to 

specific treatment issues and strategies across substance abuse treatment services. In the last 15 

years, women-specific substance abuse research and gender-responsive treatment strategies have 

dramatically increased, thus providing this TIP with a wealth of women-specific resources to guide 

its development. This TIP provides clinical and administrative information to assist counselors, 

clinical supervisors, program administrators, and others working with female clients with substance 

use disorders on how they can best respond to the specific treatment needs of women. The TIP will 

provide researchers and clinicians with a guide to sources of information and topics for further 

inquiry. 

Using a biopsychosocial framework and incorporating gender-responsive principles, this TIP 

emphasizes the importance of women’s unique developmental milestones, physiological makeup, and 

the sociocultural influences that can play a significant role in treatment needs and in determining 

effective treatment planning, counseling strategies, and services. To enhance its practical 

application for substance abuse treatment providers, this TIP features “Clinical Notes” that 

highlight relevant issues for counselors, “Clinical Activities” that provide counselors with clinical 

tools to use with clients, and “Advice to Counselors and Administrators” that present an overview of 

the main clinical and programmatic issues pertinent to a particular treatment issue for women. 

HHS Publication No. (SMA) 09-4426
 

Printed 2009
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
 

Substance Abuse and Mental Health Services Administration
 

Center for Substance Abuse Treatment